
CIass_Zl 

Book 

Copyright N° 

COPYRIGHT DEPOSE. 



THE NOSE, THROAT AND EAR 
GI LE 



THE 

NOSE, THROAT AND EAR 

THEIR 

FUNCTIONS AND DISEASES 

A TREATISE UPON 

THE BREATH-ROAD, FOOD-ROAD AND 
ACCESSARY ORGANS 

BY 

BEN CLARK GILE, M. D. 

INSTRUCTOR IN OTOLOGY IN THE UNIVERSITY OF PENNSYLVANIA AND FORMERLY AS- 
SISTANT IN THE THROAT AND NOSE DISPENSARY OF THE UNIVERSITY HOSPITAL: AS- 
SISTANT IN THE DEPARTMENT FOR THE NOSE, THROAT AND EAR AND DISPENSARY 
CHIEF AT THE PRESBYTERIAN HOSPITAL: CONSULTING LARYNGOLOGIST TO 
THE TAYLOR HOSPITAL AND FORMERLY INSTRUCTOR IN OTOLOGY IN THE 
POLYCLINIC HOSPITAL AND POST-GRADUATE SCHOOL OF MEDICINE, 
PHILADELPHIA: FELLOW OF THE AMERICAN LARYNGOLOGICAL, 
RHINOLOGICAL AND OTOLOGICAL SOCIETY. 



WITH 131 ILLUSTRATIONS, EIGHT OF WHICH 
ARE PRINTED IN COLORS 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 



n 05 



Copyright, i 9 i S) by P. Blakiston's Son & Co. 



THE. MAPLE. PHESS.Y 



ORK.PA 



CT 27 1915 

CU414276 



PREFACE 

In recent years Laryngology has developed at a rate equalled 
by few of the other specialities. Many morbid conditions have 
been investigated, described and classified; new operations 
have been devised and new instruments invented. These 
advances have been accompanied by the publication of many 
essays, theses and monographs, whose wide circulation proves 
that the subject has interest for many beyond the group of those 
pursuing it as an exclusive vocation. A stage has now been 
reached where the accumulation of facts, recorded by numerous 
observers, is so great as to demand of the student a long period of 
study, and to severely tax his memory. This is, indeed, but 
one phase of the difficulty which besets all medical study — 
too much to learn — the difficulty which has forced the colleges 
to more than double the length of the curriculum. 

With every hour of the longer under-graduate course already 
appropriated, and the field of knowledge growing broader con- 
tinually, it is imperative to economize time and to employ 
efficient methods of study; or the man entering upon practice 
may find himself not equipped, but burdened by a mass of 
information imperfectly acquired and inaccurately remembered, 
a mass which, large as it is, does not supply what he needs in his 
daily work. Among those holding staff positions in hospitals 
the complaint is general that many assistants are poorly pre- 
pared and yet these assistants are picked men, chosen for their 
supposed competence. 

The most practicable corrective of our present difficulties is 
the improvement of methods of study. To retain ten separate, 
unassociated ideas puts more strain upon the memory than to 
recollect a hundred classified ideas, which constitute a mnemonic 
chain, each link possessing qualities which suggest the adjoining 
links by a natural association. The great importance of a 
logical sequence of ideas, not only to the reasoning faculty, but 
also to the memory, is shown in some of the older sciences, as 



VI PREFACE 

for example chemistry, which by long development have 
attained a measure of exactitude, nearly mathematical, and in 
which thousands of facts are so acquired and remembered that, 
when needed, they can be brought up by a chain of association. 
Laryngology is a branch of science, whose growth is too recent 
to render it exact. It gives opportunity for only a partial classi- 
fication and such opportunity as it does offer has not been 
utilized. This is very much to be regretted since, being a spe- 
cialty, its teaching is almost wholly post-graduate and there is 
very little opportunity for didactic lectures or systematic 
instruction in any form. With slight exception, the training is 
clinical and this is unsystematic; because the order in which 
topics are presented depends upon the material available. 
When the class is assembled, the first case may be one of 
aphonia due to acute laryngitis; the second case otitis media; 
the third patient may have an adenoid and the fourth a foreign 
body in the nose. When facts are presented in this way, a 
great many are soon forgotten and, even worse, the student 
forms the habit of thinking in an illogical and slipshod manner. 
When afterward, in his own office, wholly dependent on his 
own resources, he encounters an emergency, he is in the plight 
of the journeyman mechanic, who tries "to think up what the 
boss did, when he was in such a fix." Instead of this hap- 
hazard guessing, the specialist's mind should be so trained, that 
the character of the emergency itself would call up by a chain of 
associated ideas the exact remedial procedure required. 

We cannot expect to secure for our specialty more time in the 
crowded under-graduate curriculum; nor can we change the 
trend of clinical teaching, which must continue to utilize the 
cases which chance brings into the teacher's hands; but there is 
a way of improving this post-graduate course; a way simple and 
yet quite efficient. That way is to coordinate the clinical 
demonstrations with the didactic teaching of a systematic text 
book. Such a book should be read with care at the outset of the 
special course and the essential principles and most important 
facts fixed in the memory; then, after each day's clinical demon- 
strations, the lessons learned should be compared with the chap- 



ters dealing with those same subjects, resemblances and diverg- 
ences should be considered and note taken of new statements 
which are significant. So working, the student will gradually 
and naturally incorporate what he sees with what he has read; 
text book and clinics will supplement each other, scattered facts 
will find their proper place and relation, and he will acquire a 
body of systematized knowledge, which will be his very own 
and which will come to his aid as promptly and as surely as the 
letters of the alphabet. The text book, so studied, should be 
his companion through the years. New works he will read, 
new operations he will perform, new ideas assimilate; but all 
will fit into their proper places, in the framework created during 
his period of preparation ; and the book in every part, the notes 
upon the margins, the memoranda upon interleaved pages, 
even the dogear marks and soils upon the paper, will be so 
associated with his thought and work, that no other volume 
can possibly take its place. 

A number of text books have been published, both here and 
abroad. Much credit is due to their authors for fidelity and 
industry in collecting facts and, in some cases, for elaborate and 
instructive illustrations, anatomical and surgical. In the 
matter of systematic arrangement these works are open to 
criticism. In some of them logical plan is so completely 
ignored, that the order of chapters in the table of contents 
might be reversed, without affecting the value of the book. 
Even the various sections of a single chapter may be as separate 
and independent as the articles by different writers collected 
in some encyclopaedia of medicine. These books are indeed 
storehouses; but much like the freight room of a railroad, they 
contain articles of the most diverse character heaped together 
indiscriminately. The reader, striving to memorize the valu- 
able truths presented, lacks altogether the aid of sequence and 
association and, unless specially gifted, he will forget more than 
he retains. 

In composing the following book, I have taken as my basis a 
few anatomical facts, which together with their physiological 
relations underlie the normal condition of the part of the body, 



Yll] PREFACE 

with which we are specially concerned. Modifications of these 
relations and of some accessary functions cause the processes 
of disease, whose study from various standpoints constitutes the 
scientific foundation for pathology, diagnosis and therapeutics. 
Although a complete classification is not possible, the majority 
of our facts can be grouped in accordance with such a plan, and 
its adoption makes practicable a logical succession of ideas so 
connected that, when wanted, they can be recalled by natural 
associations of thought. 

While fully conscious of defects in the execution of this plan, I 
believe that the system adopted will aid both students and 
practitioners, by economizing their time and rendering their 
knowledge more available, thus conferring a real benefit upon all 
who devote themselves to this highly important and most 
interesting specialty. 

In the following pages I have availed myself of the labors of 
many laryngologists, both native and foreign, who through 
books, lectures and personal conversations have given me 
instructions of the highest value; but I have mentioned few 
names, unless they were necessary to identify some operation 
or some instrument. This course has been followed because 
bibliographical matter is inappropriate in a treatise, whose aim 
is to give in the most compact form the practical information 
needed by the student and clinician. I specify here only those 
to whom my obligation is greatest; but I wish to ackowledge 
indebtedness to many others who have contributed to the com- 
mon fund of knowledge from which we all draw. Our grati- 
tude for what we receive is best expressed by contributing to 
this common stock something approved by our own experience 
and which will be of value to our colleagues. 

To my former teachers, Drs. Charles S. Potts, B. Alexander 
Randall and George C. Stout, I return most cordial thanks for 
the interest they have shown in my work; for the use of their 
valuable libraries placed at my disposal and for many other 
proofs of their highly valued friendship. 

Ben Clark Gile. 

1906 Chestnut Street, 
Philadelphia. 



CONTENTS 

INTRODUCTION 

CHAPTER I 

Page 

The Scope of Laryngology i 

CHAPTER II 
Diagnosis and Etiology 6 

CHAPTER III 
The Armamenta 14 

RHINOLOGY 

CHAPTER IV 
The Nasal Septum . . . 37 

CHAPTER V 
Nasal Neoplasms 62 

CHAPTER VI 
Nasal Extranea 71 

CHAPTER VII 

Rhinitis 75 

CHAPTER VIII 
Nasal Infections 99 

CHAPTER IX 
The Nasal Sinuses in 

CHAPTER X 
Nasal Disfigurements 144 

CHAPTER XI 

Nasal Relations to Special Senses 153 

ix 



X CONTENTS 

CHAPTER XII 

Page 
Epistaxis 161 

PHARYNGOLOGY 

CHAPTER XIII 
The Nasopharynx 168 

CHAPTER XIV 
Chronic Nasopharyngitis 171 

CHAPTER XV 
Adenoids 177 

CHAPTER XVI 

Nasopharyngeal Neoplasms 188 

CHAPTER XVII 

Pharyngitis 191 

CHAPTER XVIII 
The Uvula 198 

CHAPTER XIX 
The Faucial Tonsils 204 

CHAPTER XX 
The Lingual Tonsil 231 

LARYNGOLOGY 

In narrow sense 

CHAPTER XXI 

The Larynx: Form and Function 235 

CHAPTER XXII 

Laryngitis 244 

CHAPTER XXIII 

Laryngeal Infections 255 

CHAPTER XXIV 
Laryngeal Neoplasms 272 



CONTENTS XI 

CHAPTER XXV 

Page 

Laryngeal Extranea 279 

CHAPTER XXVI 
Laryngeal Neuroses 283 

OTOLOGY 

CHAPTER XXVII 
The Ear: Form and Function 288 

CHAPTER XXVIII 
Aural Examinations 306 

CHAPTER XXIX 

The External Ear: Deformities and Diseases 326 

CHAPTER XXX 
The Middle Ear: Tubal Obstruction 344 

CHAPTER XXXI 
Simple Otitis Media: Acute and Chronic 350 

CHAPTER XXXII 
Purulent Otitis Media: Acute and Chronic 364 

CHAPTER XXXIII 
Mastoiditis 380 

CHAPTER XXXIV 
Otosclerosis 400 

CHAPTER XXXV 
Internal Ear Diseases 406 

CHAPTER XXXVI 

Intracranial Complications of Ear Diseases 425 

CHAPTER XXXVII 

Deafness and Muteness 436 

Index 445 



ILLUSTRATIONS 



Figure Page 

i . Schema of the breath-road and the food-road 4 

2. The patient's chair 15 

3. The electric sterilizer 18 

4. A bracket lamp 19 

5. The head mirror 20 

6. An automatic air compressor 21 

7. Regulator of air pressure and gauge 22 

8. The ether vaporizer and air comminutor 22 

9. Davidson hard rubber atomizer 23 

10. The insufflator 24 

11. Gruber aural specula 24 

12. Laryngoscope handle and assorted mirrors 25 

13. The tongue depressor 25 

14. The Politzer air bag 26 

15. The auscultation tube 26 

16. Siegle's otoscope and Delstanche masseur 27 

17. The Dench-Galton whistle 28 

18. Randall's tuning forks 29 

19. The nasal septum with mucous membrane intact 38 

20. The nasal septum : mucous membrane removed ......... 39 

21. Septal deviation with convexity of middle turbinal 42 

22. Mial's saw 42 

23. Operation for deformity of the septum 44 

24. Flap operation upon the septum . . . 46 

25. Asch-Douglass operation upon the septum 46 

26. Simpson-Bernay intranasal tampons 47 

27. Instruments for Asch-Douglass operation 48 

28. Instruments for submucous resection of septum 49 

29. Detaching the mucous membrane by "teasing" 51 

30. The nasal speculum holding back detached membranes .... 52 

31. The swivel knife returning to starting point 53 

32. The Hurd forceps engaging edge of vomer 54 

33. The Asch forceps grasping vomer 55 

34. Deflection of columnar cartilage 56 

35. Submucous application of Galvanic cautery 58 

36. Ribbon operation for perforation of septum 59 

37. Flap operation for perforation of septum 60 

38. Nasal polypi in the left nostril 62 

39. The cold wire snare 65 

xiii 



X1V ILLUSTRATIONS 

Figure 

40. Nasal fibroma in the left vestibule 

41. Hematoma upon the nasal septum ' 6 g 

42. Interior view of the right wall of the nose. .'.'.'. „ Q 

43- Removal of anterior part of middle turbinal ... 

44. Hypertrophic tumors: posterior ends of lower turbinate ' i 

45- Removal of hypertrophic tumor with wire snare ^ 

46. Ulcerating, syphilitic gummata upon septum ....'. Facing 106 
47- Gummata of nasal bones, causing disfigurement. 

48. Skiagraph during life of the nasal sinuses IIT 

49- The nosogenic region of the nose 

50. Ballenger's ethmo-turbinate knives ^ 

51. Operation upon nosogenic region, leftside 

52. Second position of knife in severing nosogenic mass . Il8 

53. Morbid mass removed from nosogenic region 

54. Ccakley's sinus illuminator 

55- Cohen's hand drill for opening the antrum ...... 

56. Caldwell-Luc operation upon the antrum 

57- Duplex transilluminator for frontal sinuses 

58. Sullivan's frontal sinus rasps 3 ° 

59- First stage of Killian frontal sinus operation 

60. Second stage of Killian frontal sinus operation 

61. Mosher's operation: entering the fronto-nasal canal ' T , 8 

62. Final stage of Mosher's operation 

63. Operation upon sphenoid sinus 

64. Injection of paraffin for nasal disfigurement. . )** 

65. Tampons applied to check epistaxis l6 g 

66. Characteristic physiognomy produced by adenoids . . . . x 8 

67. The same patient six months after adenectomy . . ' l8l 

68. Adenoids grasped by Brandegee forceps l86 

69. Removal of adenoids completed with curette .... ' 1 g 6 

70. Fibro-cystic polypus in vault of the pharynx ...... l8o 

71. Seller's uvula scissors . 



72. Bimanual operation to shorten the uvula 

73- Follicular or lacunar tonsillitis .... 

74- Ulcerative tonsillitis: Vincent's angina . 
75. Diphtheria: patches of pseudo-membrane. 



201 



73- Follicular or lacunar tonsillitis Facing 210 

74- Ulcerative tonsillitis: Vincent's angina "212 



76. Chronic or hypertrophic tonsillitis . . "216 

77- Instruments used in tonsillectomy . . 

78. First stage in operation of tonsillectomy .... 22 , 

79- Second stage in operation of tonsillectomy 

80. Tonsillectomy completed with cold wire snare . 

81. Appearance of the fauces after removal of right tonsil 226 

82. Mathieu's tonsillotome, chain and crosspiece 

83. The tonsillotome encircling the tonsil 22c 

84. A lingual tonsil greatly hypertrophied "33 

85. Cartilages of the larynx seen from behind 236 



ILLUSTRATIONS XV 

Figure Page 

86. Laryngeal musculature, posterior view 237 

87. Laryngoscopic image of a normal larynx 239 

88. Vertical section of larynx in the median line 240 

89. Tuberculosis of the larynx 255 

90. Tuberculosis, destruction of the true vocal cords 257 

91. Tubercular, papillary growths in interarytenoid space 257 

92. Infiltration of arytenoids and of right vocal cord 257 

93. Intubation of the larynx: epiglottis bent toward tongue .... 268 

94. Intubation : the tube passes over epiglottis into larynx 268 

95. Intubation: withdrawal of obturator and introducer 269. 

96. Intubation: final withdrawal of tube by extractor 270 

97. Papilloma of the larynx 272 

98. Incorrect posture in direct laryngoscopy 275 

99. Correct posture in direct laryngoscopy 276 

100. Bilateral paralysis of adductor muscles '..... 287 

101. Paralysis of recurrent nerve on right side 287 

102. Paralysis of arytenoid muscle with inflammation 287 

103. The auricle or pinna, the visible part of the ear 293 

104. The membrana tympani ". - '. 295 

105. Interior aspect of the outer wall of middle ear 298 

106. The labyrinth with bony wall partially removed 299 

107. Passage of the Eustachian catheter 315 

108. The fungus, aspergillus niger, from external meatus 339 

109. Two views of recurrent carcinoma of auricle Facing 342 

no. Retraction and thinning of membrana tympani 360 

in. The appearance of the drum-head after inflation 362 

112. Purulent otitis media: drum-head distended with pus 364 

113. Hewitt's apparatus for dislodging cholesteomata 371 

114. Cold wire snare for use in aural operations 372 

115. Polypus protruding through ShrapnelFs membrane . . . Facing 372 

116. Hartmann's cutting forceps 373 

117. Injection of anesthetic prior to ossiculectomy 375 

118. Instruments for operating on the ossicles 376 

119. Permanent perforation through Shrapnell's membrane 379 

120. Permanent orifices in drum-head and chalk deposits 379 

121. Instruments for the simple mastoid operation 386 

122. Mastoid cortex exposed over site of the antrum 389 

123. Position of the finger upon bone-cutting gouge 390 

124. Antrum and cells converted into one cavity 391 

125. Instruments for the radical mastoid operation 395 

126. Removal of all partitions between antrum and tympanum . . . 396 

127. Slitting of the external auditory canal 397 

128. The formation of rectangular flaps: external meatus 398 

129. Rotating chair complete with douching attachment 411 

130. Landmarks to locate brain abscesses 433 

131. Extension of dermal incision: brain abscess 434 



NOSE, THROAT AND EAR 



CHAPTER I 
THE SCOPE OF LARYNGOLOGY 

The five orifices of the head, the mouth, nostrils and ears, 
with the adjoined passages and contiguous structures, con- 
stitute a well-defined region, which though of- small extent 
furnishes the stage for some of the most important and wonder- 
ful manifestations of vitality. This region is the province of 
our specialty and it is unfortunate that medical nomenclature 
furnishes no comprehensive term, distinctively expressing 
the sum of our knowledge concerning it. Its divisions have 
suitable names: rhinology comprehends everything relating 
to the nose; otology all that pertains to the ears; but we have 
no inclusive designation covering the entire ground. To 
supply the need for such a word, laryngology has been given 
a wide meaning which embraces that of the other terms. It 
is consequently used in two senses: its primary signification 
which pertains to the larynx only, and a derived signification 
of inclusive scope, and this is now the more common sense, 
so that when one speaks of laryngology, he means the entire 
speciality, comprehending under the title rhinology, otology 
and pharyngology, as well as laryngology in the narrow mean- 
ing of the word. 

The region with which we are concerned has anatomical and 
physiological relations with other parts of the organism, 
which should be thoroughly understood at the start. A correct 
and useful idea of these relations can be acquired and remem- 
bered by regarding the body, exclusive of the limbs, as com- 



2 NOSE, THROAT AND EAR 

posed of two cylinders, irregular in contour and parallel in 
position. The posterior cylinder consists of the spinal column, 
an osseous tube expanding at the top into the skull. This 
tube with its spheroidal extension contains the spinal cord, 
the brain, and the cerebro-spinal fluid. Within it are located 
most of the centers of neural and psychic functions. 

The anterior cylinder is somewhat shorter, but of much 
greater circumference. Throughout its length, from the 
lips to the anus, it is traversed by a canal (prima via) lined with 
mucous membrane and permitting the passage of gases, liquids 
and small solid bodies. Its walls consist chiefly of bones, 
muscles and adipose tissue, and between them and the central 
canal are the visceral organs, all of which are concerned in the 
essential and complex process of nutrition. This cylinder 
comprises three regions, in each of which the soft tissues of the 
walls are attached to bony frames and further sustained by 
the lateral processes of the spinal column. 

The lower region accommodates the abdominal and genito- 
urinary organs, its soft tissues being supported by the bones 
of the pelvis. The middle region, or chest, contains the re- 
spiratory and circulatory organs and its mural framework 
consists of the ribs and sternum. In the upper region the soft 
parts are suspended from the bones of the face and their contour 
is maintained by attachments to the cervical vertebrae. 

This third region extends vertically from the base of the skull 
to the sternum and includes everything in front of the spinal 
column. In the adult its perpendicular diameter measures 
six or seven inches and the length of transverse diameters 
varies from three to five inches, in accordance with the part 
of the face or throat through which they are drawn. The 
region thus occupies a very small space, but it has many 
features peculiar to itself and which prove to the earnest 
student a source of unfailing interest and the incentive to 
persistent study. Its most striking peculiarity is that the 
organs located within its boundaries are of less importance 
than are the two passageways; the breath-road and the food- 



THE SCOPE OE LARYNGOLOGY 3 

road; by which it is traversed. The disabling, even the re- 
moval, of the organs is not necessarily fatal and, to some 
degree, compensation for their abolished functions can be 
made by organs in other regions, but the breath-road and the 
food-road are indispensable; occlusion of the one entails death 
by suffocation; of the other death by starvation. To keep 
these roads open is an imperative indication of treatment 
and entire freedom of movement is so important that ob- 
struction, more or less serious, is the common factor present 
in nearly all the diseases requiring our attention. The ac- 
tivities of the organs contiguous to these highways are in 
large measure auxiliary to the unimpeded passage of air 
and of solid and liquid nutriments; but there are some whose 
functions are accessary and which, though highly important, 
are not necessary to this movement and hence not essential 
to life. 

The organs accessary to the breath-road are: (i) the terminals 
of the olfactory nerves furnishing the sense of smell, (2) the 
ears, the instruments of hearing and (3) the vocal cords, 
producing the voice. Similarly, the accessories of the food- 
road are: (1) the teeth, (2) the salivary glands and (3) the 
terminals of the gustatory nerves supplying the sense of 
taste. The complex process of articulate speech, restricted 
to the human race, and developed much later than voice and 
the special senses, results from the cooperative action of 
many organs anatomically associated with the food-road 
though, as it is a development or elaboration of voice, its 
physiological place is with the functions accessary to 
respiration. 

Fig. 1 shows in a diagrammatic way the routes of the great 
roads mentioned, and designates the functions of the accessary 
organs. 

The scope of our specialty, viewed in its varied aspects, 
may be summarily stated as follows: Anatomically it em- 
braces the upper region of the anterior cylinder of the body, 
the roads traversing it and the organs auxiliary and accessary, 



NOSE, THROAT AND EAR 




Fig. i. — Schema of the breath-road (animae via) and the food-road (prima 
via). In the pharynx the two roads coincide. The words smell, hearing and 
voice indicate the functions of the organs accessary to the breath-road. The 
words mastication, insalivation and taste are in a similar way associated with 
the food-road. 



THE SCOPE OF LARYNGOLOGY 5 

located within its bounds. Physiologically it includes the in- 
gress and egress of respired air, the course of solids and liquids 
along the food-road, the activities correlated with these 
movements and the functions of accessary kind comprehend- 
ing those causing the phenomena of the special senses of 
smell, hearing and taste and those producing voice and ar- 
ticulate speech. Clinically it considers the obstacles of every 
sort, which obstruct the normal movements along the roads, 
investigates their causation and attempts their removal. 
It investigates the pathogenic substances which enter through 
the orifices and work mischief within the region, or migrate be- 
yond its boundaries and do harm to other parts of the organ- 
ism. It endeavors to prevent or repair damage of this kind. 
It also deals with the abnormalities and diseases of the ac- 
cessary organs, especially those concerned in the highly 
important functions of audition, phonation, and articulation. 
There are some topics extraneous to this classification, 
but their number is small and the outline here given furnishes 
what, in the light of our present knowledge, is a just idea of 
the Scope of Laryngology. 



CHAPTER II 
DIAGNOSIS AND ETIOLOGY 

The importance of diagnosis is recognized by every one. 
Failures to reach a correct result are often due to an erroneous 
method of reasoning, but are attributed to ignorance, careless- 
ness, or even greed, and seriously damage a physician's reputa- 
tion. These truths are exemplified by the following illustration. 

A man had an obscure neurosis which produced spasms of 
some of the involuntary muscles. The attacks occurred at 
irregular intervals and lasted for a few hours. Deglutition 
was much impaired and there was retention of the urine and 
faeces. The trouble was of long standing ; but did not prevent 
the patient attaining a high place in the financial world. When 
he was fifty years old, there occurred a marked exacerbation of 
the bladder symptoms, which became continuous. Urination 
was frequent, but scanty; sometimes the stream would be sud- 
denly interrupted and vesical discomfort was almost constant. 
The patient applied to a professor in one of the medical colleges, 
who went into the history of the case very fully and gave the 
opinion that the seat of the disease was in the cord and spinal 
nerves. He did not explore the bladder, or make a chemical 
examination of the urine ; but instituted active treatment with 
ergot, galvanism and counter-irritation over the perineum and 
spine. 

This was continued several weeks, but the patient's condition 
grew steadily worse, until he yielded to the anxious solicitation 
of his wife and put himself in the hands of one, who had formerly 
cured her of an acute illness. This doctor, who had not a 
tythe of the professor's reputation, heard the patient's story 
without comment and then, at once, passed a sound through 
the urethra. The instrument had scarcely entered the bladder 

6 



DIAGNOSIS AND ETIOLOGY 7 

when it struck a solid body, which was afterward shown to be a 
large calculus. Its removal by lithotomy put an end to the 
lately developed bladder symptoms; but the old neurotic 
manifestations continued with little change. 

The professor's mistake was not due to haste; certainly not 
to ignorance; for he had discovered and removed many calculi. 
The fault was in his process of reasoning. Impressed by the 
history, he had from the start regarded the cause as neural and 
his subsequent thinking was influenced by this preconceived 
opinion. When the treatment proved inefficient, he should 
have reexamined the grounds of his diagnosis; but with over- 
confidence he continued to use the remedies adapted to his 
theory of the case and gave slight heed to the significant changes 
in the function of urination, neither making a test of the fluid, 
nor exploring the bladder. 

This blunder was of the kind which make an impression 
upon the laity. It cost the professor much in loss of reputation 
and brought many reproaches from the business and social 
acquaintances of the patient. If the diagnosis made by 
analysis had been compared with results obtained by the syn- 
thetic method, the mistake would have been avoided. 

Similar errors in reasoning appear to be frequent and just as 
common among men, who have had five or six years of college 
and hospital instruction, as among the product of the old 
course of two short terms. If the present-day graduate is 
deficient in the reasoning needed for correct diagnosis, that 
deficiency should be made up by postgraduate instruction, 
hence the matter will be briefly considered here. 

The analytical method of diagnosis is indispensable and is used 
at every bed side. The clinical data comprise the following: 

i. The symptom complex, or description of the case. 

2. The history furnished by the patient or others cognizant 
of the facts, a narrative going back as far as the doctor desires, 
or the conditions permit. 

3. The physical examination: knowledge the doctor gains 
by using his own senses and such assisting instruments as the 



8 NOSE, THROAT AND EAR 

stethoscope, clinical thermometer, laryngoscope, urethral 
sound, sphygmomanometer, etc. 

4. Perhaps, the laboratory findings regarding various normal 
or abnormal substances derived from the patient's body, or in 
some way associated with him. Such information, chiefly of a 
chemical and microscopical sort, is not usually required, the 
diagnosis being established by the data under the other three 
heads; but, in cases of doubt, this supplementary information is 
frequently invaluable. 

These four categories include the Res omnes propria Morbi, 
the sum of knowledge upon the subject. It is by analyzing 
these data, proceeding from the known, to the unknown, 
working from effects back to causes, that the clinician reaches 
a concept of the origin of the symptoms, the physical signs and 
the laboratory findings. That origin he recognizes as identical 
with one of the diseases he has studied and in designating that 
disease he expresses the results of his diagnostic investigation. 
Nine times out of ten he will be right, but in a few instances 
he may overlook some of the facts, or give them too little 
weight; in other cases he may attribute an effect to one cause 
solely, ignoring another cause, which is equally capable of 
producing that effect. In such ways he may go astray and 
when on the wrong road wander further and further from the 
right pathway. 

It is just under these circumstances that the synthetic 
method proves exceedingly valuable, because it corrects the 
errors of the analytical plan. It has fallen into neglect with the 
decay of didactic teaching but every physician should under- 
stand it and should resort to it, whenever the diagnosis is doubt- 
ful and especially when he is disappointed in the effect of his 
therapeutic measures; because the failure of remedies, which 
usually succeed, is a mandate to reinvestigate the diagnosis. 

The synthetic plan of study begins with general morbid 
processes and then considers the important diseases, one after 
another, striving to gain a concept of each; a mental picture, 
in which the chief characteristics are so depicted that when 



DIAGNOSIS AND ETIOLOGY 9 

seen in practice they will be easily recognized thus identifying 
the actual malady with the idea retained by the memory. In 
making a diagnosis the symptoms and other data are compared 
with those mental concepts, which relate to organs and func- 
tions within the same range of thought, and conclusions are 
drawn from the resemblances and divergences. 

If this method had been used in the illustrative case given 
above, the steps in the reasoning process would have been as 
follows: There is vesical pain, frequent, scanty urination, and 
sometimes sudden interruption of the flow. Do these symp- 
toms correspond with the features of any disease of the genito- 
urinary system? The memory calls up, one by one, the mental 
concepts of diseases of this group. Stone in the bladder has 
held a place in nosology for over twenty centuries ; some of its 
well-known symptoms are identical with those of the present 
case, hence a stone may account for the phenomena. At all 
events, there is here sufficient probability to impose the duty 
of exploring the bladder, and if this does not give positive 
results, of analyzing the urine. The bladder exploration would 
have given positive results to the professor, as it afterward did 
to the other physician, and the diagnosis would have rested 
upon a safe and certain basis. 

The practitioner of long experience may rapidly reach a 
correct diagnosis, though even for him there is danger in haste, 
but the beginner should proceed carefully and deliberately, 
omitting no step of the reasoning process. He will thus form 
the habit of thoroughly covering the field and oi reaching a 
diagnostic conclusion, which he can both accept and defend. 
Every abnormality observed should raise in the mind of the 
diagnostician four etiological questions. Their asking and 
answering will promote a habit of thinking logically and 
comprehensively and will prove a valuable safeguard against 
error. These questions are helpful to every doctor; but 
specially so to every laryngologist. 

First stands the inquiry: Is this abnormality congenital? 
In the structures contiguous to the breath-road and food-road 



IO NOSE, THROAT AND EAR 

anatomical variations are quite frequent and some of them are 
congenital. They may be slight and compatible with full 
functional activity and yet may give trouble when an operation 
is performed. For example, a redundant anastomosis may 
render a haemorrhage much harder to control. The importance 
of the question referred to is made manifest by an inquiry of 
almost daily occurrence. There is an organ in an abnormal 
state and there also exists a detrimental process. Is the latter 
caused by the former? We find that while the process has 
lasted six months the abnormality is congenital. Obviously, if 
it were the cause of the process, that process would have begun 
long before: its cause lies somewhere else; hence operating upon 
the organ will not change the process. Such mistaken opera- 
tions have often been done with most disappointing results. 
If an abnormal condition is not congenital, it must have been 
produced later and this fact leads to the second inquiry: 

Is this abnormality traumatic? People often forget acci- 
dents, particularly those which happened in childhood, and 
careful questioning may be necessary to elicit the story of some 
injuiry received in school days, but the knowledge is well 
worth the trouble it costs. Suppose there is a cicatrix in the 
vestibule of the nose: it makes a great difference whether 
this scar is the vestige of a wound or of a syphilitic ulcer. 
The nasal and pharyngeal membranes often bear the marks of 
former operations and these signs may be the clues to former 
conditions, having an important bearing upon the patient's 
present situation, and may give much aid toward a correct 
diagnosis. 

In the third place, comes the inquiry: 

Is this abnormality due to some hidden foreign body? It is 
not here intended to refer to bacteria; but to those extranea, 
either animate or inanimate, which if uncovered are visible to 
the naked eye. Such intruders are more numerous than is 
commonly supposed. The rhino-laryngeal region, like the 
coat of St. Lazarus, is full of holes. These cavities furnish 
hiding places for extraneous things of many sorts, sometimes 



DIAGNOSIS AND ETIOLOGY II 

of very curious and unlikely description. The length of time 
such foreign bodies remain undiscovered is often as strange as 
the things themselves. Where there is any possibility of their 
presence the physician should look for them. If properly 
made, the inspection can do no harm and, in an unexpectedly 
large proportion of cases, it will disclose articles of which the 
patient is unaware. These things are harmful and may cause 
not only the obstructive, inflammatory and degenerative 
troubles, which we would naturally anticipate, but also secon- 
dary and remote damage of a most unexpected kind. Our 
minds should be alert to this possibility; for the removal of 
some long concealed foreign body has, in a number of instances, 
caused the cessation of distressing symptoms, although' no 
etiological relationship had been established. Usually, when 
we have found such an intruder, our duty is plain: with rare 
exceptions, its removal is the safe and proper course. This 
procedure sometimes impresses the popular imagination, 
particularly where the body extracted is of an unusual or 
grotesque kind, and the surgeon gains a higher reputation than 
rewards work requiring much greater skill. The importance 
of inspecting the cavities in which some foreign body may be 
hidden, in every case where the diagnosis is obscure and the 
treatment unsuccessful, is well shown in the following narrative. 
A mine owner of Arizona, overtaken by darkness in the 
mountains, had slept all night upon the sandy ground. The 
next day he was attacked by a severe frontal headache, which 
slowly yielded to medical treatment; but returned some weeks 
later and afterward recurred, at irregular intervals, for a period 
of two years. The pain was accompanied by dizziness and 
some confusion of thought. If the patient tried to walk in a 
straight line he was deflected to one side and, if the eyes were 
closed, this deflexion increased to a nearly circular movement. 
The physicians, to whom he applied, were mystified and failed 
to do him any good. The last in order advised rest and travel; 
so the patient went to Germany and consulted several pro- 
fessors of renown. They began treatment hopefully, giving 



12 NOSE, THROAT AND EAR 

him baths (of course) and mineral waters and massage and 
electricity. It was all of no avail and the patient resolved to 
give up physicians and go home " to grin and bear it." During 
the ocean voyage, a fellow-passenger persuaded him to make 
one more effort for recovery by consulting a Philadelphia 
physician in whom she had great confidence. 

To this doctor's mind the headache and circular locomotion 
suggested the possibility of disease in the labyrinth of the ear 
and his first question regarded the aural condition. To his 
amazement, he learned that, from first to last, no one upon 
either side of the Atlantic had examined the ears. Five 
minutes later he withdrew from the left meatus the dead body 
of a" small moth, which the patient recognized as belonging to a 
species of poisonous insects common upon the southwestern 
plains. Its feet and mouth had been adherent to the membrana 
tympani, which showed a sub-acute inflammation. For this 
the doctor gave treatment; but he encouraged no great expecta- 
tions, simply remarking that some benefit would result from 
the removal of the moth, which doubtless had crept into the 
patient's ear during the night he slept upon the ground two 
years before. The sequel proved that irritation communicated 
from the external ear to the delicate structures within, was the 
sole cause of the long-continued disturbance, for as the drum 
head became normal, all the symptoms disappeared and, in a 
week's time, the patient, enthusiastically grateful, resumed his 
homeward journey, a well man. 

One inquiry remains : 

Is this abnormality due to micro-organisms? Bacteriology 
is so habitually present in our thinking, that there is small 
risk of overlooking its etiological importance; the danger is 
rather that we may attribute too many things to the activity 
of microbes. Many acute diseases are undoubtedly due 
to them and their presence may be inferred from clinical 
signs, without an actual demonstration. If we are on debat- 
able ground, then recourse must be had to the laboratory with 
its chemical and microscopical tests. The laboratory findings 



DIAGNOSIS AND ETIOLOGY 1 3 

are a part of our diagnostic data and as evidence may be con- 
sidered upon the same plane with the other premises upon 
which the conclusion is based. The laboratory expert should 
expect nothing more than this. The claim that the data he 
furnishes are more trustworthy, more scientific, than what the 
clinician finds, is utterly baseless. Mistakes are as fre- 
quent in the laboratory as elsewhere and, when the establish- 
ment is run upon a wholly commercial plan, its reports are of 
little value. In some such places the actual testing is done 
by incompetent female employees of the shop-girl type and 
the results deserve no confidence whatever. The necessity 
of a division of labor has forced physicians to resort to an 
outside laboratory for part of their information, but in doing 
so they introduce an element of doubt and the danger of error 
is greater than if the entire investigation was made by the 
clinician himself. If he were obliged to take another man's 
report of the cardiac and pulmonary sounds, instead of using 
the stethoscope himself, his faith in the diagnosis would be 
shaken and the danger of fallacious results would be greatly 
increased. Similar doubts and dangers are inherent in the 
second-hand statements coming from the laboratory outside 
the physician's office. 

Proper replies to the four diagnostic questions, which have 
been considered, will cover the etiology of the majority of the 
abnormal conditions encountered in practice. The remaining 
inquries are not numerous and will present little difficulty 
to one who has faithfully followed the method of investiga- 
tion here advised, and has thus eliminated what is congenital, 
traumatic, extraneous and bacterial. 

When the physician has by patient and intelligent investi- 
gation established a diagnosis, which fully satisfies his own 
mind, he can proceed to the treatment actuated by a confidence 
that will impart purpose and force to his therapeutic measures, 
and also inspire the patient with a hopefulness leading him to 
cooperate heartily in all the efforts made for the restoration 
of his health. 



CHAPTER III 
THE ARMAMENTA 

The word armamcnta, sanctioned by long usage, is the 
most convenient term to designate the material equipment 
of the specialist, as its signification includes instruments, 
drugs, apparatus, furniture, everything indeed required for 
both diagnosis and treatment. In selecting the articles, two 
needs should be borne in mind: First, the need of those things, 
which will be demanded in the event of an emergency; such 
as syncope, or profuse haemorrhage. Whatever else is lack- 
ing, these articles must be at hand; for their absence may 
mean a catastrophe. The second need is for the things most 
frequently employed in the diagnosis and treatment of the 
common diseases; those which make up the bulk of every 
practice, unless it is of a very unusual kind, work which con- 
stitutes what may be called the daily routine. The man, 
who is not supplied with these, will be constantly embar- 
rassed and at a great disadvantage when compared with his 
competitors. 

Whether the beginner's outfit should go beyond the supply 
of these two needs is partly a matter of individual taste and 
partly a question of financial ability. Any considerable 
surplus should be avoided. Money spent for unused in- 
struments is a wholly unproductive investment and, while 
some patients may be favorably impressed by an extensive 
display of apparatus, the effect upon others is just the reverse. 
The following list is intended to include the armamenta re- 
quired by emergencies and by routine practice, leaving some 
special contrivances to be described in connection with the 
operations for which they have been devised. 



THE ARMAMENTA 15 

The patient's chair, shown in Fig. 2, should measure about 
eighteen inches from the floor to the seat; the back should ex- 
tend eighteen inches and be surmounted by a head rest ten 
inches high. Its four essentials are that it should stand firmly 
upon the floor; that it should rotate freely and noiselessly at 
the level of the seat; that the back should be quickly made 




Fig. 2. — The patient's chair. 



horizontal, putting the patient in the recumbent posture; and 
that the head rest should be adjustable to a horizontal plane, 
without disturbing the back. Many models of such a chair 
are on the market. The one which provides these essential 
features by the simplest and plainest construction is the best. 
In this and every other article, avoid what is complicated and 



1 6 NOSE, THROAT AND EAR 

ornamental. What is simple is least likely to get out of order, 
is most easily repaired, when it has been damaged, and is most 
readily kept clean and aseptic. 

The surgeon's stool is plainly constructed of hard wood 
with four stout legs and a circular seat, to which both rotation 
and perpendicular movement are imparted by a metallic screw 
eight inches long. It is better to bring the operator's hands 
to the proper level with the patient's ear, nose or mouth, by 
raising or lowering the seat of his stool, than by making any 
change in the patient's position. The cabinet for instruments 
should be large enough to accommodate the articles without 
crowding. Both the doors and shelves should be of glass, 
so that dust or dirt of any description may be readily detected 
and removed. As there is seldom need for haste in replacing 
metal instruments upon the shelves, the danger of breaking 
the glass is slight. 

The instrument table holds those implements needed in 
the procedure under way and also the drugs required for 
anaesthesia, for checking haemorrhage, or any other purpose 
connected with the particular work in hand. It brings within 
the surgeon's reach what he needs in treating the patient 
then before him. For that purpose it is very convenient and 
almost essential, and to that purpose it should be restricted. 
It is bad practice to encumber the table with articles left after 
previous operations, with books or, indeed, anything except 
the few necessaries required by the work of the hour. If the 
table is encumbered by extraneous things, it loses half its 
value, which consists in momentarily offering to the operator 
just the things he wants and nothing else. Restricted to such 
proper use, the table need not be large and the smaller the 
area occupied by instruments, the surer one is to grasp quickly 
the article needed. 

This table should be supported by four smooth, cylindrical 
legs of ample strength to insure stability and its top should be 
a round-cornered rectangle, each side of which measures from 
eighteen to twenty inches. Glass is scarcely a suitable material 



THE ARMAMENTA 1 7 

for this top, because metal articles may be dropped upon it 
with some force and a fracture of the glass is a costly accident, 
and may also greatly disturb a nervous patient. Marble is 
easily spoiled by eroding chemicals, which may be accidentally 
spilled. A satisfactory material is oil- finished oak, and perhaps 
even a better is a slab of slate, a substance which resists most 
chemicals and is much less likely to break superimposed glass 
vessels than is either metal or marble. One or two additional 
chairs may be needed. For aseptic reasons they should be 
free from cracks and crevices, also from cushions and upholstery 
of every sort. 

The washstand should have a flow of both hot and cold 
water. This is readily available in most cities and towns. 
When the office is in a house, whose water-heating apparatus 
cannot be relied on, the defect can be overcome by interposing a 
gas-heated coil in the course of the service pipe. A fountain 
cuspidor, which can be kept clean at all times, should be con- 
nected with the pipe giving drainage to the washstand. 

A three-leaved toilet mirror, fastened to the wall above the 
washstand, will prove convenient to lady patients in adjusting 
their head wear. 

In a corner of the office may stand a plain cabinet of some 
hard wood, finished with oil. Its height should be about three 
and a half feet, its length two feet and its depth one foot and a 
half. A swinging door of wood held by a simple catch, not 
lock, should occupy one of the longer sides. The lower part 
of the inclosed space should accommodate a pail of agate ware or 
similar material serving as receptacle for soiled gauze, cotton 
and detritus of every sort, except what is washed away in the 
fountain cuspidor and basin. Above this should be placed 
two shelves, not drawers, to hold towels, napkins and various 
articles unsuited for a place behind the glass doors of the 
instrument cabinet. The protection of the clothing of patients 
can be effected at the smallest cost by adjusting under the 
chin a Japanese paper napkin retained by a neck band of white 
tape a foot long, upon each end of which is sewed one of those 



1 8 NOSE, THROAT AND EAR 

little clamps used in elastic garters to grip the upper margin of 
the half-hose they support. 

The firm and level top of this cabinet is a good situation for 
the sterilizer. This is virtually a vessel in which instruments 
are subjected to the aseptic influence of boiling water. In its 
conventional form, as furnished by the instrument makers, it 
is a rather costly machine to accomplish a very simple purpose ; 
but the use of this type is so widespread that its purchase 
seems expedient. The required heat may be produced by 
burning oil, or gas; but it is better to use electricity, if available. 




Fig. 3. — The electric sterilizer. 

The electric sterilizer, illustrated in Fig. 3, is a rectilinear vessel 
of sheet copper furnished with nonconducting handles and 
having the legs tipped with porcelain. A tray, holding the 
instruments to be boiled, rests upon supports within the 
receptacle and can be lifted out of the water, when the exposure 
to high temperature has been long enough for thorough steriliza- 
tion. This immersion in boiling water should last ten or 
twelve minutes and the instruments should then be wiped 
thoroughly dry, for if they are replaced in the cabinet while 
moist, burnished steel surfaces may in a few hours be damaged 
by rust. 

A good artificial light is indispensable and its first requisite 
is a satisfactory bracket, which combines strength and stability 
and has both perpendicular and horizontal motion. Fig. 4 



THE ARMAMENTA 



I 9 



shows a bracket lamp which has the necessary features. The 
metal retaining plate on the right is to be securely fastened to 
the studding of the wall, or some other firm support. Through 
this plate pass the electric wire and gas pipe which extend 
through the two sections of tubing. The joint close to the 
retaining plate and a second joint, at A, impart to the tubes 
both a vertical and a lateral motion, so that the lamp may be 
adjusted to any position desired. This bracket should be so 
located that the patient's chair may be brought close to it and, 
as it will be used continually, it should be very strongly made: 
weak joints soon get out of order. The material employed is 




Fig. 



■A bracket lamp. 



generally bronze or gun metal. At the end of the tubing, on 
the left, is the lamp, which may be gas or electric, the latter 
being preferable since it gives less trouble and radiates but 
little heat. To the lamp should be attached a Mackenzie 
condenser, to concentrate the rays of light. 

The head mirror (Fig. 5) to reflect light upon the place under 
inspection is circular, slightly concave, and has in the center a 
hole which is kept directly over the pupil of one of the phy- 
sician's eyes. The diameter of this hole should not be more 
than three-eighths of an inch. This mirror is supported 
by a head band, best made of a single piece of sheet metal 



20 NOSE, THROAT AND EAR 

sufficiently resilient to remain steady, but not making undue 
pressure. The mirror should have a focal distance of about 
seven inches and a diameter of three and a half inches. 

The electrocautery is much less used than formerly, but is 
still employed in treating tubercular growths and dilated 
blood vessels. It has the advantage that the loop or cone can 
be introduced and also withdrawn cold, the high temperature 
lasting only while there is a closed circuit. Its current can be 



supplied by a storage battery, or derived from the ordinary 
house wiring by employing a modifier. 

Compressed air is useful for so many purposes that it 
should be at all times available. There is need for a machine 
operated by some readily applied power, and which will work 
automatically. This machine should be capable of furnishing 
air in ample amount and under sufficient pressure to meet all 
probable requirements, and its construction should be such that 
it will not readily get out of order and that it can be bought at a 
moderate price. 

The IXL Automatic Air Compressor, shown in Fig. 6, with 
the addition of a reservoir similar to the galvanized iron boilers 
attached to kitchen ranges, has proved, in my experience, a 
practicable and durable machine and its cost is not prohibitive. 
Its motive power is derived from the flow of water in the service 



THE ARMAMENTA 21 

pipes which are connected with the water main in the street 
and, in residential houses, it is commonly placed in the cellar, 
whence a pipe conveying the compressed air leads up to the 
office. In the upper stories of very high buildings, the remote- 
ness of the cellar makes this plan expensive and the apparatus 




Fig. 6. — An automatic air compressor. 

should, if possible, be accommodated upon the same floor with 
the office. The IXL compressor requires little attention and 
rarely gets out of order; it is not clogged by muddy water and 
does not need hand pumping to start the machinery. It gives 
one pound of air pressure for each pound'of water pressure, and 
as soon as the pressure in the reservoir falls below a designated 



NOSE, THROAT AND EAR 



minimum, the hydraulic motor starts automatically and the 
pressure is increased. The maximum pressure in city water 
mains is much greater than can be used with safety in many of 
the cases where compressed air is em- 
ployed, and the office should contain a 
mechanism for reducing and regulating the 
force. A device of this kind (Fig. 7), 
which is simple and durable, can readily 
be procured. It is furnished with a gauge 
showing the exact pressure under which the 
air passes into the delivery tube and, by 
the turn of a single thumb screw, this 
pressure can be regulated with entire ac- 
curacy. This delivery tube is furnished 
with a closure valve very near the end 
which connects with the atomizer, and by 
this valve the air current can be immedi- 
ately cut off. In addition to apparatus of 
this sort, the physician should have a small 
and simple hand pump, as a resource in case of any accident 
to the machine or its pipe connections. 




Fig. 7. — Regulator of 
air pressure and gauge 




Fig. 8. — The ether vaporizer and air comminutor. 



The apparatus for ether-vapor anaesthesia, including the 
intratracheal (Fig. 8), consists of a jar partly filled with 



THE ARMAMENTA 



23 



ether and standing in a vessel of hot water. The vapor 
mingles with a current of air passing through the upper part 
of the jar, the proportion of each substance being regulated 
by stop-cocks. The mixture is carried to the patient by a 
flexible tube. The air which comes from the compressor, at 
a density indicated by a pressure gauge, is passed through a 
Wolff's wash bottle; but when the air is forced through this 
bath in large bubbles, they retain dust and motes which 
have not been given time to sink. A more efficient device 
for cleansing is the air comminutor — a large glass jar (Fig. 8) 
almost filled by fragments of aseptic 
cotton loosely arranged. The air 
entering at the bottom of the jar 
is subdivided into minute jets by a 
circular sheet of fine wire gauze 
and then in traversing the mass of 
cotton deposits the solid particles 
it has borne along and, when it 
emerges through the exit tube at 
the top of the jar, it is almost en- 
tirely clean. 

When it is desired to convert a ^H 

liquid into the form of spray, the Fig. 9-— Davidson hard-rubber 
^ . . atomizer. 

nebulizing is effected by driving a 

rapid current of air across the orifice of a capillary tube. The 
instruments invented for this purpose are almost numberless, 
but for the usual office work a Davidson hard-rubber atomizer 
will be found sufficient (Fig. 9). 

The vacuum aspirator consists of a jar from which the air 
is partly exhausted by a hand suction bulb. To this is at- 
tached a rubber tube connected with an aspirating needle. 
It is used to withdraw liquids, serum, pus, etc., in cases where 
a free incision is objectionable. 

The insufflator is a contrivance for scattering powders, 
such as bismuth subnitrate, over surfaces like those of the 




24 



XOSE, THROAT AXD EAR 



nasal cavities. The medicament is carried by puffs of air 
impelled by a rubber hand bulb (Fig. 10). 

The so-called nasal douche, which sent a jet of water up 
one of the nostrils to return by way of the other, or to run into 
the pharynx, was a dangerous instrument, as the injected 
liquid mixed with purulent secretions was liable to enter the 
Eustachian tube and carry infection to the middle ear. If 
we wish to use in the nostrils a very gentle stream (and none 
other is allowable in either the nose or the ear), the bulb syringe 
made entirely of soft rubber and one 
ounce in capacity is the best device for 
the purpose. 

Of the various nasal specula, the 
Ingals and Bosworth have given me 
the most satisfaction. In aural specula 
my preference is for those of the 
Gruber type (Fig. n). They come in 
sets of three or five, giving a proper 





Ooo 



Fig. io. — The insufflator. 



Fig. ii. — Gruber aural specula. 



assortment of sizes. They are elliptical in cross-section, cor- 
responding to the form of the meatus, and are made of highly 
polished metal. 

It is necessary to have forceps, shaped for use in the nose, 
ear and larynx, adapted for seizing and removing foreign 
bodies and for applying dressings. Cutting forceps are nec- 
essary for the removal of polypi. Mackenzie's laryngeal 
forceps and the Tobolt laryngeal probe are useful instruments. 
Aural and nasal applicators are shaped much like a probe and 
have the distal end somewhat roughened to give a hold upon 
cotton or other fibrous substance wrapped around it. An 



THE ARMAMENTA 



25 



applicator with a corkscrew end is convenient when one 
wishes to carry a pledget to a certain spot and leave it there, 
for by turning the applicator from right to left, it is easily 
disengaged. The point of the screw must be very blunt, to 
avoid harm from a turn in the wrong direction. 




Fig. 



-Laryngoscope handle and assorted mirrors. 



The laryngoscope consists of a set of circular mirrors of 
graded size, each being attached to a short wire shank. These 
shanks fit into a common handle of polished metal, to which 
they can be securely fastened by a set screw. The size of 
the mirror used depends 
wholly upon the circum- 
stances in each case examined 
(Fig. 12). 

The tongue depressor is 
designed to hold the tongue 
in its natural posture while 
at rest, when it fills the 
elliptical cavity bounded by 
the curve of the lower jaw. 
Very little pressure should 
be put upon the tongue; it 
should simply be restricted 




3. — The tongue depressor. 



to its horizontal position, so as to permit an unobstructed view 
of the fauces and the organs posterior to it. One of the sim- 
plest and best instruments for this purpose is a semicircular 
band of metal (Fig. 13). The ends have an elliptical curve 
and both are corrugated on the inner surface, giving a hold 
upon the tongue and a good grasp for the hand. 



26 NOSE, THROAT AND EAR 

The Politzer air bag (Fig. 14), a rubber bulb of pyriform 
shape with a flexible tube terminating in a nose-piece, is fre- 
quently used for inflating the Eustachian tube. The bag 
should have a capacity equal to eight fluidounces of water; 
smaller sizes are not efficient. Sometimes the air expelled 




The Politzer air bag. 



from the bag passes without difficulty through the Eustachian 
orifice and hence along the tube to the middle ear. In other 
instances it is necessary to employ a Eustachian catheter. 
The best material for this instrument is pure silver; it is softer 
than the alloyed metal and a catheter made of it can be bent 




Fig. 15. — The auscultation tube. 

at any curve and will retain that shape, while many other 
flexibles spring back to their original shape. In judging by 
sound whether the injected air has actually reached the middle 
ear, the auscultation tube is useful. It is simply a rubber 
pipe about two feet long fitted at the ends with a white and 



THE ARMAMENTA 



2 7 



a black ear-piece. One of these rests in the auditory meatus 
of the patient, the other in that of the surgeon, and when the 
air reaches the middle ear, its entrance is distinctly heard 
(Fig- 15). 

Siegle's pneumatic otoscope (Fig. 16) is an instrument 
of conical shape having at the base a magnifying lens and 




Fig. 16. — Siegle's otoscope with the Delstanche masseur. 



at the apex an elastic ring which so fits the meatus as to render 
it a closed chamber, in which the air is condensed or rarefied 
by the action of a hand bulb. This instrument is improved 
by replacing the bulb by Delstanche's masseur, a small piston 
pump which always produces suction, thus rarefying the air 



2& NOSE, THROAT AND EAR 

in the external ear and drawing the drum membrane outward. 
When air is allowed to reenter, the membrane retracts by 
its own elasticity. This to and fro movement has been called 
"massage of the ear drum." It is useful in both diagnosis 
and treatment. 

There are two instruments constantly employed for test- 
ing the hearing and for making differential diagnosis when 
it is impaired. One is Dench's modification of the Galton 
whistle (Fig. 17). It is inexpensive and not easily injured and 
gives with accuracy the tone for which it is adjusted. This 
whistle is made upon the principle of a closed organ pipe and 
its pitch extends through several octaves, ranging from about 




Fig. 17. — The Dench-Galton whistle. 

1700 (1677) vibrations, per second, to 40,000. As the in- 
strument is seen in the shops the current of air is produced 
by an atomizer bulb with valves at the orifices. This is ob- 
jectionable, for the movements of these valves produce ex- 
traneous noises, rendering the primary tone impure. This 
difficulty can be removed by substituting the valveless, soft- 
rubber bulb of the aural syringe. 

Another important instrument is the tuning fork. This has 
been long used by musicians because it is almost indestructible 
and always gives forth an unchanging tone. For otologic 
purposes tuning forks are commonly furnished in sets of five. 
In each set there is one which gives 256 double vibrations per 
second, producing a tone of the same pitch as belongs to the 
middle C upon the keyboard of the piano. On this account 
the figures 256 are often inscribed upon this fork. The other 



THE ARMAMENTA 2Q 

four produce higher or lower tones, separated by intervals of 
one octave, and their vibratory numbers are obtained by 
using two as a divisor (128) or as a multiplier (512, 1024, 2048, 
etc.). Dr. Randall's forks (Fig. 18) are the most satisfactory, 
as they have been continually improved until, in their pres- 




Fig. 18. — Randall's tuning forks. 

ent state, overtones are nearly eliminated and that too with- 
out adding to the prongs metal bands or any other attachment. 
Hasmostats and artery forceps are a necessary part of the 
instrumental equipment as also is a good hypodermic syringe, 
whose needles should be short and of rather large lumen. 
Long needles are liable to bend in penetrating the skin and a 
minute bore is readily clogged. 



30 NOSE, THROAT AND EAR 

There are three aids to diagnosis so universally used that 
every physician is presumed to possess them, whether he is 
or is not a specialist. These are the clinical thermometer, the 
stethoscope and the sphygmomanometer. They are too 
familiar to require description, but it should be said that 
attention has recently been drawn to the great significance of 
blood-pressure tests in tonsillitis, which is so often an etiological 
factor in nephritis. The rapidly rising blood pressure is often 
the first recognized signal of the intercurrent renal disease. 

It appears unnecessary to occupy space by a description of 
the scalpel, bistoury, probe and other articles included in the 
pocket surgical case. This small assortment of necessary 
instruments is familiar to almost every graduate long before he 
takes up the study and practice of any specialty. Need for 
their use may occur at any time in almost any office. 

In accordance with the purpose expressed at the beginning of 
this chapter, the list of remedies here given includes those 
employed in the usual routine of practice and those needed in 
emergencies and which should be instantly available in a form 
to produce immediate effects. Other valuable medicines will 
be considered in connection with the diseases to which they are 
applicable. Liquids injured by light are best kept in cylindrical 
phials of clear glass inclosed in dark-colored cartons, which 
leave the glass stopper protruding. These phials are better 
than those made of blue or other opaque glass, because the 
quantity and condition of the liquid can be inspected by with- 
drawing the paper cover, which also protects against breaking. 

The need for very prompt action is usually the reason for 
giving a hypodermic injection, and this need requires that the 
remedy should be in the liquid state and readily absorbable. 
Nevertheless, many men have discarded hypodermic solutions 
and depend upon the tablets which, though soluble, necessarily 
involve delay. They have submitted to this delay because of 
the frequent and serious mistakes occurring with solutions of 
the dangerous alkaloids. Both danger and delay can be 
wholly avoided if the physician makes his own solutions in the 



THE ARMAMENTA 3 1 

following way: Decide upon a standard dose of each alkaloid, 
a beginning dose safe for immediate injection; dissolve twelve 
tablets of this strength in half a fluidounce of water C.P. 
and filter the solution into an ounce bottle, wide necked and 
glass stoppered, upon which is gummed a plain label bearing 
the name of the medicine and the dose. When the injection is 
required, fill the hypodermic syringe directly from the bottle 
and administer its entire content, assumed to be twenty 
minims, as this is the usual capacity of the stock syringe upon 
which this calculation is based. Suppose the substance to 
be sulphate of morphia and the standard dose one-fourth 
grain. If to twelve tablets half a fluidounce, or 240 minims, 
of water has been added, twenty minims, or the content 
of the syringe, will contain a quarter grain of the drug. Just 
so in every other case; when the syringe is filled by suction 
from the bottle holding the solution, the syringe contains the 
exact standard dose of the intended remedy in a form adapted 
to immediate absorption. The only things to remember are 
the standard doses and the fact that a syringe full always repre- 
sents them. There is scarcely a possibility of error. Besides 
sulphate of morphia, there may be needed for hypodermic 
injection sulphate of atropia Qfoo g ram )> sulphate of strychnia 
(3^0 g ram ) an d digitalin, not digitoxin (34 grain). 

Ammonia is a powerful cardiac stimulant and, as it is freely 
evolved from the stronger water of ammonia, this solution 
should be kept in a small, rubber-stoppered phial. If syncope 
occurs, three or four minims should be dropped upon a frag- 
ment of cotton or gauze, which should be held near the patient's 
nostrils — a much safer plan than holding the open bottle to the 
nose. 

Alcohol is astringent, antiseptic and stimulant. For the last- 
named purpose it is given by the stomach, and this organ is more 
tolerant of the liquors produced by distillation than of synthetic 
solutions made by mixing alcohol with water and other sub- 
stances. Genuine brandy, that is, the distillate of pure grape 
wine, is the ideal diffusible stimulant. In the treatment of 



32 NOSE, THROAT AND EAR 

shock its superiority over other alcoholics is so manifest that I 
believe it influences metabolism in some way they cannot. 
Unfortunately, genuine brandy is costly and fabricated sub- 
stitutes are so common that the real thing is hard to procure 
at any price. As a diffusible stimulant, its place is best 
supplied by a pure, well-matured whiskey made from rye. Of 
this an eight-ounce bottle should be kept on hand. 

For use as an astringent in otitis media and other cases it is 
not necessary, as some authors advise, to keep four or five 
dilutions of pure alcohol. This encumbers space with too 
many bottles. Four ounces of the spiritus rectificatus of 
the pharmacopoeia (sp. gr. 835), which contains sixteen per cent, 
water, is sufficient, as any dilution wished for can be readily 
made by adding distilled water, which mingles at once with 
alcohol in all proportions and at all temperatures. 

To stop bleeding our main reliance is upon ligatures, pack- 
ing and cold, but oozing from capillaries may be controlled 
by remedies which coagulate the albumen of the blood. Sodium 
perborate is one of the best. It is a powder which upon the 
addition of water generates peroxide of hydrogen. Applied 
to a bleeding spot with a moist pledget of cotton upon the 
tip of an applicator, it almost immediately causes coagula- 
tion. If a vegetable styptic is preferred, tannic acid, eight per 
cent, in glycerine, can be used with a similar instrument. 

A two-ounce bottle of each of these drugs should be pro- 
vided and others are scarcely needed, as these meet the in- 
dications for haemostatic remedies. 

To produce ischemia or blanching of the tissues, chloride 
of epinephrin is very efficient; but its effect soon disappears 
and the constricted arterioles regain their usual size. An 
ounce phial of the common solution, one part to a thousand 
(1 :iooo) is a sufficient supply since exposure to the air causes 
a decomposition, marked by a change in color, and a part of 
even the small quantity mentioned may require to be thrown 
away. The ratio, 1 : 1000, gives a stronger solution than is 



THE ARMAMENTA 33 

usually necessary and this may be diluted, when used for 
spraying, to the proportion of i : 10,000. 

Astringents of many kinds are in use to meet certain indi- 
cations in various forms of relaxation; but the following are 
sufficient for habitual employment. The familiar tincture 
of the chloride of iron has, in addition to astringency, an al- 
terative influence upon the mucous membrane. It should be 
applied with a cotton wisp, to be rejected immediately after- 
ward, as it attacks brushes, corks, and most metals. Care 
should be taken to prevent its touching the teeth, since it 
rapidly destroys their enamel. 

Guaiacol in proportion of two fluidrams to six of pure, 
fresh, olive oil may be applied by a swab in pharyngeal and 
tonsillar inflammations. The compound tincture of benzoin 
is a mild astringent applied in a similar way, particularly in 
sub-acute and chronic inflammations. 

Chemical caustics can be employed for the same purposes 
as the galvanocautery, if the office is not provided with the 
electrical appliances. A fused bead of chromic acid adherent 
to the end of a probe is drawn lightly over the surface to 
be affected, so that contact is made in parallel lines very 
near together. The acid withdraws all water from the super- 
ficial layer of tissue, thus devitalizing it. Chromic acid 
should. not be applied to a large area at one time, because if 
absorbed, it may injure the kidneys. 

Nitrate of silver varies in effect from a mild stimulant to 
an escharotic, in accordance with the strength of the solution 
used. This remedy should be kept in two bottles, glass stop- 
pered and protected from light. The first should contain ten 
grains of the crystalline nitrate in one fluidounce of water, 
this giving very nearly a two per cent, solution, applicable in 
all instances where a mild effect is in view. In the second 
bottle should be put 360 grains of the silver salt with enough 
water to make one fluidounce, producing a seventy-five per 
cent, solution capable of the stronger action of the drug. 
This strong liquid coagulates albumen, closes the blood and 



34 NOSE, THROAT AND EAR 

lymph passages and, in general, does the work of a caustic. 
Solutions to produce intermediate effects are readily pre- 
pared by adding water to the strong fluid, e.g., one part of 
this plus two parts water gives a strength of twenty-five 
per cent., very useful for some purposes. Caution should 
be observed in applying silver nitrate to the throat that none 
of it drops upon the larynx to which it is injurious, hence the 
cotton wet with the solution should be securely held by the 
applicator and all superfluous liquid be absorbed by a pad, 
before the throat is treated. Another caution is to avoid the 
solid stick of fused nitrate, which though valuable for some 
purposes, is dangerous in nose and throat work. There is 
risk that the stick may be broken, or may slip out of the 
caustic holder and a fragment drop into the oesophagus or, 
much worse, into the trachea. 

Carbolic acid is a very efficient drug where we desire a 
diffused and superficial cauterization. It does not penetrate 
deeply and causes hardly any pain. For this use as a caustic, 
the pure crystalline phenol should be employed with the addi- 
tion of just enough glycerine to liquefy it. In this strength the 
acid is safer than when diluted, as the escharotic action pre- 
vents absorption. 

Detergent applications are required in many instances to 
remove crusts, pus, adherent dust and other impurities. They 
should be used gently, for the purpose is not to scrub the mucosa, 
but to soften and loosen the accretions which will then be 
easily removed. Inspissated pus is rapidly decomposed by 
the peroxide of hydrogen, which should be diluted with an 
equal quantity of water, if the solution on hand is the three 
per cent, combination usually sold. This drug should not 
be sprayed and it should be allowed slow action, a little at a 
time, so that there may be but slight frothing. This caution 
is specially necessary when treating the ear for the gas forcibly 
disengaged has been known to drive purulent particles into 
the mastoid cells. 

D obeli's solution has a well-established reputation as a 



THE ARMAMENTA 35 

cleanser of the nose and throat. It can be employed in full 
strength or diluted, and either as a spray or with a cotton 
swab. The formula is : 

1$. Sodii bicarbonatis 5j 

Sodii biboratis o j 

Acidi carbolici gr. xv 

Glycerini fig j 

Aquae distillatse q.s. ad. Oij. M. 

This remedy proves of most value in inflammations, which 
have reached a sub-acute or chronic stage. While the process 
is acute, better results follow the use of the normal salt solution. 
In many cases this is the best possible application and the fact 
that it is a constituent of healthy blood and most other somatic 
fluids often gives it an advantage over substances which are 
foreign to the organism. 

Sprays of oleaginous composition do good by soothing and 
protecting irritated tissues. Camphor and menthol, in the 
proportion of two grains of each in a fluidounce of an excipient, 
make a useful preparation for routine work. The best vehicle 
for such drugs is the officinal petrolatum liquidum. 

In idolent ulcers and wherever the reparative process requires 
stimulation an excellent application is the thymol-diiodide 
(aristol), a compound of iodine, which has largely superseded 
iodoform, long in general use. It possesses the advantages of 
being less toxic than iodoform and being free from that drug's 
very unpleasant odor. It may be used in its simple state as a 
powder, or made into a ten per cent, ointment, or dissolved in 
oil, in which it is quite soluble, although very little of it is 
taken up by water. Stearate of zinc is emollient and mildly 
astringent. For external use it is free from danger; it produces 
no stains and is wholly odorless. Subnitrate of bismuth 
sprinkled upon surfaces, denuded by operation, forms a 
mechanical shield which is protective and somewhat sedative. 
Calomel may be used for the same purpose. These powders, 
being insoluble, should not be allowed entrance to narrow 
passages or cavities difficult of access. If a dry powder is 



36 NOSE, THROAT AND EAR 

wanted in such situations, borax and boric acid, which are easily- 
dissolved, are much safer. 

Local anaesthesia is of very great importance in laryngological 
practice, not only as an essential condition in many operations, 
but to reduce the discomfort often attendant upon diagnostic 
procedures and also as a factor in the therapeusis of some 
diseases. There are two drugs capable of producing this 
condition which should be kept ready for use viz: solution 
of cocaine hydrochlorate and solution of novocain. Their 
dosage and mode of action is similar but the novocain is far 
less toxic and is to be preferred in patients who have an 
abnormal susceptibility to cocaine. Accidents from local anaes- 
thetics are far less frequent in our work than in general surgery, 
because we apply the drug to the mucous membrane, which 
slowly absorbs it from cotton or some other fabric soaked by 
the solution; hence if some untoward symptom appears, 
when only a small fraction of a grain has been taken up, the 
balance of the dose can be withdrawn. This opportunity does 
not occur when, as is common in other regions, the entire dose 
is given in one hypodermic injection. It will be advisable to 
keep on hand a one-ounce bottle of each anaesthetic, the solution 
being made by dissolving twenty grains of the salt in a 
fluidounce of water, with the addition of five grains of 
antipyrin as a preservative. These are practically four 
per cent, dilutions and are efficient, if enough time be allowed 
for absorption by the mucous membrane. The addition of a 
few drops of the solution of epinephrin chloride already 
described will promote ischaemia and lessen the reaction liable 
to follow the use of local anaesthetics. Though the procedure 
here outlined is attended by little danger, the surgeon must 
bear in mind that twenty-five minims of the solution contain 
a grain of the principal drug which, if it be all absorbed, is a 
full dose. If the application is made slowly, a less quantity 
will generally produce the local effect desired. For employ- 
ment as a spray, the four per cent, solution should be diluted 
with an equal quantity of water. 



CHAPTER IV 
THE NASAL SEPTUM 

In Chapter I, the Scope of Laryngology, attention was directed 
to the paramount importance of the two great passageways 
which traverse the naso-pharyngeal region — the breath-road and 
the food-road. Their occlusion is fatal and their obstruction, 
in even a slight degree, is seriously detrimental, such obstruc- 
tion of one or the other constituting the common factor in 
most of the diseases we are called upon to treat. 

The normal course of the breath is through the nostrils, the 
route by way of the mouth being supplementary. In traversing 
the curved passageways, from the nasal vestibule to the 
pharynx, the inspired air is warmed, moistened and, in slight 
measure, filtered, some of the solid particles it carries being 
caught by the vibrissas, the hairs within the vestibule, while 
others are entangled by the viscid mucus bathing the irregular 
surface of the walls. When one finds it hard to breathe 
through the nose he opens his mouth, thus utilizing the sup- 
plementary oral route, but upon this route the warming and 
moistening of air are done very imperfectly and the filtering 
not at all. This deficiency in preparing the atmosphere before 
it goes to the lungs is the first evil in a long train of injurious 
effects dependent upon mouth breathing, if that substitution 
of the supplementary route, in place of the nasal breath-road, 
becomes a permanent practice. 

Much time and ingenuity have been devoted to differentiat- 
ing the various nasal obstructions to determine whether they 
interfere chiefly with inspiration or with expiration. This is a 
refinement of little practical utility. If the mouth is opened 
to assist one-half of the respiratory act, it will remain open 
during the other half and, if the need for assistance continues, 

37 



3 8 NOSE, THROAT AND EAR 

the habit of mouth breathing will be acquired. It matters 
little whether the original difficulty was with inspiration or 
expiration. 

The two parallel passageways of the nose may be narrowed 
at any point and the encroachment may come either from their 
outer walls or from the partition by which they are divided. 
This partition, called the septum, has an important place in 




Fig. 



19. — The nasal septum with mucous membrane intact. 



rhinological surgery, as morbid changes in its shape are re- 
sponsible for much obstruction and they frequently require 
operative correction. 

The septum is formed by the perpendicular plate of the 
ethmoid bone above and the vomer below, with the addition of 
the septal cartilage. In articulating with each other, the two 
bones leave toward the front a triangular space, and this is 
filled by the cartilage which gives to the septum the shape of an 
unsymmetrical square plate with irregular margins and standing 
in a perpendicular position above the arch of the hard palate. 



THE NASAL SEPTUM 



39 



Upon each side of this plate the periosteal layer is covered by a 
network of blood vessels, lymphatics and nerves; the interstices 
are filled by connective tissue and over all are the submucous 
and the mucous membrane which here has a stratified, ciliated 
epithelium whose function should be preserved. In the layer 
composed of the submucous and mucous membranes, secreting 
glandules are very abundant. Terminal filaments of the 
olfactory nerve are distributed over the upper third of the 




Columnar Cartilage 



Fig. 20. — The nasal septum with mucous membrane removed. 



septum; its other nerves also are sensory and are branches of the 
anterior ethmoid and the naso-palatine; its arteries are derived 
from the anterior and posterior ethmoid and the posterior 
nasal. There are no muscular attachments. The septum with 
and without its mucous membrane is shown in Figs. 19 and 20. 
Morbid conditions of this structure include malpositions and 
malformations, the former often causing or increasing the latter, 



40 XOSE, THROAT AXD EAR 

since a marked deviation almost always produces unequal 
curvature of the two sides, with thickening and other changes. 
Following the plan of etiological investigation laid down in 
Chapter II, we inquire whether the morbid state of the sep- 
tum is (i) congenital, (2) due to traumatism, (3) caused by 
foreign bodies, (4) caused by micro-organisms. The third 
question may almost certainly be answered in the negative, 
as this thin plate with a fossa on either side can scarcely furnish 
a hiding place for any extraneous body; nevertheless, the 
careful surgeon will scrutinize both surfaces and, if there 
be any suspicious appearance, will examine the spot with a 
probe, either bulbous, or sharp-pointed. 

There is general agreement that marked or harmful devia- 
tions of the septum are rarely congenital, but very frequently 
developmental. In childhood the roof of the hard palate 
curves more sharply than in adult life and has been called 
the "Gothic arch." Normally this arch flattens with further 
development and in so doing gives room for the downward 
growth of the septum, but sometimes this flattening does 
not occur and then the septum, deprived of necessary space 
for proper extension, suffers a deviation and bulges laterally 
into the right or left fossa. Any diathesis, which impedes 
the normal development of the bones, may affect the ethmoid 
and the vomer and produce septal deformity (see Fig. 20). 

Traumatism accounts for many cases. Although the 
septum is less exposed to external violence than the symphysis 
of the nasal bones, constituting the bridge of the nose, yet 
the triangular cartilage is liable to be injured by transmitted 
force (counter stroke) without a surface wound and, of course, 
may be damaged to any extent by accidents which lacerate 
the tissues. 

Infections produced by micro-organisms may, by long- 
continued action, induce trophic changes leading to various 
sorts of deformity. These infections will be considered further 
on. In so far as they have caused structural alterations in 
the septum, such deformities generally require the same 



THE NASAL SEPTUM 41 

treatment as though they had a developmental or traumatic 
origin but it must be borne in mind that the prognosis of 
operations may be influenced by the basic infection, which 
may have impaired the vitality of the tissues, so as to make 
recuperation after surgical operations slow and imperfect. 

There is an important relation between septal abnormalities 
and catarrhal rhinitis. They have reciprocal etiologies; 
prolonged inflammation produces hypertrophy and deformities ; 
on the other hand, structural changes, by impeding respira- 
tion and by the harsh efforts patients make (picking, douch- 
ing, blowing) to relieve their discomfort, bring about chronic 
inflammation. When the two conditions coexist, as they 
usually do, our efforts should first be directed to the rhinitis 
and the appropriate remedies described in Chapter VII should 
be faithfully applied and only when they have failed should 
other procedures be undertaken. In many cases, after the 
patient has been cured of the rhinitis it is found that all the 
symptoms are so much ameliorated that it is not necessary 
to go further. 

This conservative method has encountered the criticism 
that, as deformities may cause rhinitis, any relief from it 
while the deformities remain will be of short duration and 
very slight advantage, a mere trivial palliation. The objec- 
tion is not well taken, as appears from instances where the 
disease has an occupational origin. A man has a septum which 
is somewhat deflected but has given no trouble. He engages 
in work of an unhealthful kind and is attacked by rhinitis 
leading to septal hyperplasia and deformity; he withdraws 
from the injurious vocation but continues to suffer from the 
combined diseases. He now comes under treatment and is 
cured of the rhinitis, slight deformity remains, together with 
the original deflection, but there is plenty of room for respira- 
tion and the obstructive symptoms disappear and do not 
return. The reason is plain. The rhinitis had been caused 
by the joint influence of the anatomical abnormality and the 
injurious vocation: the second factor having been removed, 



42 



NOSE, THROAT AND EAR 



the structural fault could not alone cause a relapse. Even 
in instances where cure of the rhinitis does not adequately 
relieve all the symptoms, it is of 
great advantage as a preliminary 
to the doing of any corrective opera- 
tion. 

Another matter should receive at- 
tention prior to any septal surgery. 
Not unfrequently there is upon the 
middle or lower turbinate bone a 
convex enlargement corresponding 
to a concavity upon the septum and 
between the two there is a curved 

sepmV^ltrelrS P assa S ewa y which, though of un- 

ment of the middle turbinal. natural shape, still gives ample room 
The heavy line shows the sec- r , i , ,,, . T , ,, 

tion made by the saw, remov- for the movement of the air. If the 
ing the bulge, before the sep- septum is straightened it will im- 
tum is straightened. . 

pmge upon this convexity and close 

the breath-road upon that side, as shown in Fig. 21. When, 
therefore, such a bulge is found upon one of the turbinals, it 
should be removed under local anaesthesia with a Mial's saw 





Fig. 22. — Mial's saw. 

(Fig. 22) or a spokeshave, the section being made so as to 
leave a raw surface parallel to the plane of the septum after 
it shall be made straight. This raw surface usually heals 
readily by granulation. 



THE NASAL SEPTUM 43 

Surgical correction of septal deviations and deformities 
makes use of osteotomy and chondrotomy, either one, or 
both in combination. These operations, when successful, yield 
good results, but they are attended by the risks incident to 
the removal of bone and cartilage in highly vascular regions 
and they require specially devised instruments and specialized 
skill on the part of the operator. They should not be per- 
formed in the presence of highly acute inflammation, or an 
actively infectious process, and are interdicted by any tend- 
ency to haemophilia. Furthermore, it must be remembered 
that minor variations in form and position do not necessarily 
impair the usefulness of the septum; indeed, slight deviations 
and little rugosities are often observed in persons, whose 
respiration and cognate functions are entirely healthy. The 
mere fact that the septum is asymmetrical or slightly deflected 
does not justify surgical interference unless there exists, as a 
consequence, obstruction to the respiration, or some impair- 
ment of the drainage and ventilation of the nasal fossae, or 
the accessary sinuses. 

When it has been ascertained that there is a morbid condi- 
tion of serious import, for which the septum is responsible, a 
very careful examination should be made to ascertain just 
what part of the septum is at fault; for it has happened, more 
than once, that operations have been performed without re- 
lieving obstructive conditions, and subsequently it has been 
shown that the cutting was done in the wrong place. 

The precise place and character of the operation having been 
determined, the nostrils should be thoroughly cleansed with an 
alkaline solution and the patient placed in a suitable position, 
either the posterior recumbent posture upon a table, or the 
upright posture in the office chair whose back can be in- 
stantly lowered in case of threatened syncope. Anaesthesia of 
the septum should be induced by applying on each side a six 
per cent, solution of cocaine followed by a solution of epi- 
nephrin chloride whose strength is one to a thousand, use being 
made of a wet, but not dripping, cotton-tipped applicator and 



44 



NOSE, THROAT AND EAR 



the process being repeated, at intervals of a few minutes, until 
the mucous membrane is ischemic and desensitized. If the 
deformity to be corrected is limited to the cartilaginous portion 
of the partition, it is more readily rectified than if the osseous 
part is involved, but the partially detached segment is harder 
to retain in its new post-operative position because the resili- 
ency of the cartilage draws it toward its former place and it 
becomes necessary to use nasal tubes or splints to prevent 
movement of the deflected segment for several days, until 
union along the severed edges is se- 
cure. Displaced segments of bone 
generally hold their position without 
such support. 

The septal conditions requiring 
correction are either deformities such 
as spurs, ridges, etc., or deviations, 
both of these generally appearing in 
conjunction. The operations for 
the first group are simpler and safer 
than those for deviations and should 
have priority in time and choice. 

formftyS^^um 1 : Heavy R ° ften ha PP ens that after the 

Ihe^w-^/t^f f. irectio u n of th orough removal of these various 

me bd.w. dotted line snows v, !_• 

wrong direction. nypertropnies the nasal functions 

are so much improved that furthei 
surgical interference is not required. Even where this favor- 
able result is not attained, the situation is much simplified and 
the operation for the deviation is made less difficult by the cor- 
rection of deformities already accomplished. 

A spur or ridge, protruding from either side of the septum and 
encroaching harmfully upon the nasal fossa, as shown in Fig 23 
may be removed as follows: With a scalpel of short, convex 
blade, cut through the mucosa and submucosa, carrying the 
incision around the edge of the protuberance slightly above its 
base; turn back the membranes away from the excrescence 
with an elevator, until the white, glistening surface of the 




THE NASAL SEPTUM 45 

cartilage comes into view. Then saw through the base of the 
spur or ridge, from below upward, keeping the saw parallel with 
the perpendicular plane of the septum, thus avoiding the 
common error of making the section at an angle diverging from 
the septum. Instead of the saw, a spokeshave may be used. 
It engages the protuberance in its fenestra and then brings its 
cutting edge into contact, when the handle of the instrument 
is forcibly drawn outward. After the removal is complete, the 
edges of the mucosa and submucosa will almost meet across the 
denuded surface, because the redundant membranes, loosened 
and turned back by the elevator, will nearly cover the space 
occupied by the base of the spur or ridge. The small sulcus 
remaining between the edges soon fills by granulation and the 
reparative process is generally complete in four or five days. 

This wound should be thoroughly dried and covered with a 
thin layer of sterile gauze, which is then well moistened with 
collodion applied drop by drop from a pipette. The drying of 
this dressing seals the wound and fully protects it from secre- 
tions and discharges. The gauze should remain until it 
spontaneously separates from the healed surface. 

Lateral deviation, causing a bulge upon one side with a 
corresponding depression upon the other, may be corrected by 
the flap or window operation; but if the convexity is due to 
thickening, so that the opposite side presents a level surface, 
this operation will not remove the obstruction, but will simply 
transfer it from one fossa to the other. 

Briefly stated, this procedure is as follows: Make a flap, 
which is either rectangular or U-shaped and which includes the 
bulging part of the septum, by cutting from the convex side 
through to the other; three edges of the rectangle, or the 
curved line of the U being incised and the flap being attached 
by the remaining margin. The edge must be beveled so that 
the area of the flap is greater upon the bulging side than upon 
the other. Forcibly push the flap through the window, made 
by the incision, to the unobstructed fossa, where it will be 
retained by the beveled edge which raises the margin of the 



46 



NOSE, THROAT AND EAR 




Fig. 24. — Flap operation upon the nasal septui 




Fig. 25 — -Asch-Douglass 



-■',; "*■ . '"en-Douglass operation upon the nasal septum. The heavv linp<; 
n ± a i e . mC1S10nS; d0tted Iines sh ™ ^ctures of the rLes of tnl S S3 



segments 



THE NASAL SEPTUM 47 

flap somewhat above the level of the surface of the remaining 
part of the septum. Granulations will form along the margins 
of the flap and of the window and these will ultimately unite 
giving, in favorable cases, a nearly symmetrical septum which 
does not obstruct either fossa. If bony structure is included 
in the flap, it will be necessary to use a saw, as shown in 
Fig. 24. 

When the deflexion is marked, a good operation is the 
Asch-Douglass shown in Fig. 25, which is done by applying 
the index-finger of the left hand to the convexity and cutting 
through the septum from the other side with a knife whose 
short, triangular blade is at right angles to its shank. This 
is called a button-hole incision and is made 
at the posterior margin of the deflexion. 
This perforation is extended by cutting with 
a curved, blunt-pointed bistoury forward 
from this point along the line of deepest 
deflexion to the anterior margin. Then 
starting at the deepest spot of the concav- 
ity the knife cuts along radii from this cen- 
ter choosing the lines of greatest deflexion. 
These incisions divide the cup-shaped de- 
flexion into several trianguloid segments p| 
having their bases at the margin of the con- fig. 26.— Simpson- 
cavity and their apices at its center. Pres- Berna y intranasal 

. x tampons, 

sure is then made on the convex side, so as 

to fracture the bases of these segments, and force them across 
to the other side of the median line. If any other misdirected 
segments require rectification, they can be dislocated from their 
attachments with the Adams- Asch forceps, by a lateral rocking 
motion. After making as good coaptation as possible, Simpson- 
Bernay intranasal tampons (Fig. 26) are introduced to support 
the segments in their new position. Union along the edges 
usually takes place in a short time and, as soon as the danger of 
displacement is passed, the tampons should be removed and 
the surface lubricated with a bland, slightly alkaline ointment. 




48 



XOSE, THROAT AXD EAR 



When no untoward interference occurs this operation gives a 
nearly straight septum with full restoration of functions. 




Fig. 27._ — Instruments for Asch-Douglas septum operation. A, Douglas 
septum knife, spear shape. B. Septum knife, blunt point. C, Douglas sep- 
tum knife. D, Septum forceps, straight. 

Instruments used in the Asch-Douglass operation are shown in 
Fig. 27. 



THE NASAL SEPTUM 



49 



An operation, at present popular, is the submucous resec- 
tion of the nasal septum. It may aid the reader to under- 
stand this complex procedure, if he will regard the struc- 
ture as a hard, stiff plate inclosed in a soft, flexible envelope. 




Fig. 28.- — -Instruments for submucous resection of nasal septum. A, Allen's 
nasal speculum, right and left; B, scalpel, small; C, Ballenger's elevator; D, 
Pott's elevator; E, nasal curette; F, nasal septum speculum; G, Ballenger's 
swivel septum knife; //, Hurd's septum forceps; '/, Jansen-Middleton's septum 
forceps; /, Asch's septum forceps. 



The purpose is to take this plate in whole or in part out of the 
envelope. A slit is cut near one end of the envelope, through 
which is passed an instrument which separates the plate 
from its covering, without penetrating the latter. Then 



50 NOSE, THROAT AND EAR 

this instrument is withdrawn to give place to another, which 
breaks up the plate and is itself withdrawn. A third instru- 
ment removes the fragments of the plate piecemeal. The 
soft, flexible envelope is now empty. The slit cut at the start 
is closed, the two sides come in contact and ultimately cohere. 
The result is a structure which upon the outside is unchanged, 
but which has lost its rigidity and its strong support. It is 
also rendered thinner by the extraction of the plate. By 
remembering the above meager outline, the consecutive steps 
of the operation may be more readily apprehended. The 
instruments used are shown in Fig. 28. 

The first step to be taken is the making of a crescent-shaped 
incision through the mucosa, submucosa and perichondrium, 
upon one side of the septum. This incision is about three- 
quarters of an inch from the tip of the nose with its convexity 
presenting in that direction. Its length is nearly an inch. 
Through this slit a small, sharp-edged elevator is introduced 
and the mucoperichondrium slowly and carefully separated 
from the underlying cartilage. After a start has been made, 
a dull-edged elevator is substituted and separation continued 
along the nasal crest as far as may be necessary, the purpose 
being to denude the chondroosseous plate over an area some- 
what larger than the segment of that plate, which is to be 
removed. When the limit in this direction has been reached, 
the divulsion is continued downward by imparting a partially 
rotary motion to the shank of the instrument which thus 
detaches the perichondrium, a process called "teasing" (see 
Fig. 29). Difficulties may be encountered, if there are ir- 
regularities upon the surface, but these usually yield to pa- 
tient and skilful manipulation of the elevator combined with 
such changes in position as can be effected by traction upon 
the tip of the nose. If such means fail, one is apt, almost 
unconsciously, to use greater force, but this is an error. It 
is much better to withdraw the steel instrument and substi- 
tute instead the small, flexible elevator devised by the late 
Dr. Potts. This instrument is made of copper, nickel-plated, 



THE NASAL SEPTUM 



51 



and has a sharp and also a blunt end. It can be bent to any 
shape and various curves can be tried until one is found 
which enables the elevator to insinuate itself around the 
opposing obstacle. The membranes peel off smoothly before 
it and it is so flexible as to bend rather than to lacerate the 
tissues. • This instrument minimizes the danger of making 
such a wound as might result in perforation of the septum, 
a most regretable accident, whether caused by an operation, 
or in any other way (see Fig. 28D). 




Fig. 29. — Detaching the mucous membrane of the septum by the rotary 
movement called "teasing." The arrow shows direction of detachment. 



When the separation has been continued down to the vomer 
the tissues will be found much more adherent and, if the 
bone is to be left in situ, the divulsion need not proceed further, 
but if the vomer is to be taken out, separation of the muco- 
perichondrium must be completed with a sharp elevator, the 
membranes being spared injury by making the incision at 
the expense of the periosteum of the vomer. Some shreds of 



52 NOSE, THROAT AND EAR 

this covering, remaining adherent to the soft tissues after 
the operation, will do no harm. 

The separation upon the right aspect of the septum having 
been completed, the next step is to make a passageway to 
the other side. For this a spot is chosen near to the primary- 
incision above the vestibule. The surgeon inserts the index- 
finger of his left hand into the left nostril, opposite the spot 




Fig. 30. — The nasal speculum holding back the detached membrane, exposing 
to view the cartilaginous plate of the septum, in the operation of submucous 
resection. 

chosen, and then cuts through the cartilage slowly and cau- 
tiously, so as not to injure the mucoperichondrium upon the 
other side. A good instrument for the purpose is a curette 
only moderately sharp. When a hole has been made through 
the cartilage it is enlarged to serve for the introduction of 
the elevators with which the mucoperichondrium upon the 
left side is separated from the central plate by the same 
process as was used upon the right side. The septum speculum 



THE NASAL SEPTUM 



53 



is now inserted so as to retract the separated membranes, 
holding them out of the way and giving the operator a good 
view of the cartilaginous plate and also room to work safely 
(see Fig. 30) . If the progress so far has been free from accident, 
it has prepared the way for the second stage of the operation — 
the ablation partial or complete of the internal plate of the 
septum. This procedure begins with the chondrectomy, that 




Fig. 31. — The swivel knife is shown returning to the point at which it started, 
thus completing the separation of a segment of the septum. 

may be effected in several ways, among which the preferable 
one is the use of the swivel knife (see Fig. 28). 

It comprises three parts, a handle, a shank of two prongs, 
and a distinctive contrivance called the swivel. This is a small, 
rectangular blade with a cutting edge upon one of its longer 
sides. It swings freely between the ends of the prongs to 
which its extremities are attached by pivots. On account 
of this construction it can cut anywhere along a line de- 



54 



NOSE, THROAT AND EAR 



scribed by the points of the prongs, within a plane at right 
angles to a straight line joining the two pivots. In preform- 
ing the chondrectomy it is first pushed forward, acting in 
the manner of a gouge and making a section nearly parallel 
with the nasal crest. The prong points are then depressed 
and the swivel cuts downward, until the surgeon changes his 
force to traction, when the swivel acts like a spokeshave and 
makes a section toward the vestibule, coming back to the 




Fig. 32. — The removal of the cartilaginous plate of the septum is here indi- 
cated by the rectangle of darker color. In the vacant space are the Hurd forceps 
blades, engaging the edge of the vomer. 

starting point, having traversed the perimeter of the segment 
to be removed (see Fig. 31). The part cut away is taken out 
by dressing forceps. It has been found that such cartilage, if 
immersed in normal salt solution, will retain its vitality for 
several weeks. It can be used for repair where there has 
been recent laceration within the nose and even in plastic 
operations for old perforations. 



THE NASAL SEPTUM 



55 



If any part of the perpendicular plate of the ethmoid re- 
quires removal, it can be severed with cutting forceps (Fig. 2 81). 
The Hurd bone-cutting forceps is well adapted for removing 
a part of the vomer by clipping off its upper edge as shown 
in Fig. 32, but when the entire bone is to be ablated it should 
be firmly grasped with Asch forceps and dislocated from its 




Fig. 33. — The Asctf forceps grasping the vomer, in order to remove the bone 
entirely by disarticulation. 



articulations by a lateral rocking motion. The position of 
the instrument is shown in Fig. 33. Fragments of bone 
disarticulated, or cut away, are carefully withdrawn from the 
nostrils with nasal forceps. 

After the • removal of whatever cartilage and bone were 
included in the plan for resection, there remains a partly empty, 



56 



NOSE, THROAT AND EAR 



mucoperichondrial pouch. This should be cleansed of frag- 
ments and blood clots and then closed by the coaptation of 
its two sides which should be retained in position by Simpson- 
Bernay intranasal tampons. They can be removed in a 
few days, as the membranes soon unite, fibrous tissue ulti- 
mately forming a substitute septum. The original crescentic 
incision near the vestibule heals in a couple of days without 
suturing. 

Sometimes the only deflection present is that of the columnar 
cartilage located in the middle of the vestibule (see Fig. 34). 




Fig. 34. — Deflection of the columnar cartilage toward the left side. 



This condition is readily corrected by making an incision 
through the mucoperichondrium, parallel with the cartilage, 
turning the membranes aside and cutting away the deviated 
cartilage with blunt scissors curved on the flat. Postoperative 
treatment consists in the application to the wound of a sterile 
gauze dressing and its inunction with a bland ointment. 

Submucous resection is not a suitable operation in childhood 
and adolescence, when the bone and soft tissues have not 



THE NASAL SEPTUM 57 

reached full development. As to its value among adult 
patients, there is the difference of opinion commonly found 
regarding operations of recent introduction, whose ultimate 
standing must await the verdict of time. In its favor, the 
claim is justly made that it gets rid of the obstructive symptoms 
without impairing the septum's functional value to respiration 
and to the sense of smell. On the other hand, this operation 
weakens the support of the walls of the nose, increasing the 
danger of disfiguring traumatism. It is counterindicated in men 
particularly exposed to facial accidents, e.g., football players 
and other athletes. Other questions will be settled when, with 
the lapse of time, the remote sequels of the procedure come into 
view, as has been the case with many other operations. 

In some cases obstructive symptoms are caused by tumes- 
cence of the erectile tissue upon the upper anterior third of the 
septum. This condition may be corrected, under local anaes- 
thesia, by chemical cauterization, which for the safety of the 
functionating epithelium of the mucosa, may be effected 
beneath this membrane. A small incision is made down to the 
submucous layer. Through this hole is inserted a blunt probe 
with which the superimposed membrane is loosened and 
elevated; the probe is withdrawn and its place taken by a 
canula containing a slender rod bearing upon its extremity a 
fused bead of chromic acid. After the point of the canula has 
reached the spot where cauterization is to begin, the rod is 
pushed forward exposing the acid bead, then by drawing 
the canula outward, the bead burns a furrow and is again re- 
tracted within its sheath. Only a short furrow should be 
burnt at one sitting. Kidney disease contraindicates the use 
of chromic acid. If it cannot be employed, the galvanic 
cautery may be used in its stead, as illustrated in Fig. 35. 

Perforation of the septum does not obstruct respiration, but 
it gives rise to much annoyance and discomfort. Crusts are 
apt to form around the orifice and patients are prone to pick 
at them, making the soreness much worse and sometimes 
inducing epistaxis. Occasionally the orifice is of such a shape 



58 



NOSE, THROAT AND EAR 



that air passing through it in respiration produces a very 
audible, whistling sound. Except when due to accident, oc- 
curring during an operation, or otherwise, perforations gener- 
ally begin in the denuding of the cartilage upon one side and 
gradually break through. Hence there is time for prophy- 
lactic treatment and every effort should be made to secure 
repair of the soft parts, when injured, and to check deep ulcera- 
tion. These objects may often be attained by cleanliness of 




Fig. 35-— Submucous application of the Galvanic cautery to the nasal septum 



the nose and by applying to the diseased spot a mild astringent 
and alterative. I have found much benefit from an ointment 
containing four grains of the yellow oxide of mercury in an 
ounce of petrolatum. I apply this whether the perforation is 
complete or only threatened and in cases of both specific and 
nonspecific origin. It has proved valuable in prevention, as 
well as in palliation. 

Aside from traumatism and operative accidents, syphilis is 
the most frequent cause of perforations. There are generally 
present, at the same time, other lesions due to the same cause. 



THE NASAL SEPTUM 



59 



In all such cases the patient should be put upon anti-syphilitic, 
con stitutional treatment. 

There are two operations for the cure of septal perforations, 
both of them best adapted to cases where the opening is small. 
The ribbon operation (Fig. 36) is performed thus: Freshen 
the edges of the perforation; make a ribbon wide enough to 
cover the hole, by a curved incision through the soft tissues, on 
the right aspect of the septum; lift up this ribbon with the 
elevator, without detaching its ends, then draw it over the hole 




Fig. 36. — Ribbon operation for perforation of septum. 



and suture the freshened edge of the ribbon to the edge of the 
membranes upon the distal side of the perforation. Follow the 
same procedure in the left nostril, only taking the ribbon from 
the opposite edge of the perforation. The closure of the open- 
ing is then complete, but upon each aspect of the septum the 
interior plate is exposed through a rift from which the ribbon 
has been withdrawn. In favorable cases, this rift fills up with 
granulation tissue and the sutured edges unite, affecting a cure. 
The second, or flap, operation (Fig. 37) has the following tech- 



6o 



NOSE, THROAT AND EAR 



nique. Freshen the edges and from either side of the septum 
select the best membranous flap available. With the trailing 
swivel knife make an incision down to the interior plate in such 
a way as to furnish a circular flap, a little larger than the hole, 
attached to a membranous band which serves as a pedicle. 
Lift the flap and a part of the pedicle with the elevator and 
fold them over so that the flap covers the hole; push the flap 




Fig 



37. — Flap operation for perforation of the septum. Observe th; 
trailing swivel knife, by turning upon its pivot, makes a circular cut 



Observe that the 



through the opening far enough to bring its epithelial surface 
to the level of the epithelial surface upon the opposite aspect 
of the septum and suture the flap in this position. The result 
is that upon the side where the suturing is done, there is a 
continuous epithelial surface of the mucous membrane, while 
upon the opposite side there are two raw surfaces of circular 
shape, one produced by the reverse of the flap and the other by 
the denuded segment of the interior plate from which the flap 



THE NASAL SEPTUM 6 1 

was separated. Much granulation is required to cover these 
areas. If repair is effected and if union takes place along the 
circular line of the sutures, the operation will have accomplished 
its purpose, and the perforation will have been closed, but only 
by a single membranous layer, not, as in the ribbon operation, 
by two layers. 

After either of these operations, the repaired septum requires 
judicious care, in the way of cleanliness and protection from 
injury, to avoid a breaking down of the plastic tissue which 
seldom acquires much power of resistance. 



CHAPTER V 
NASAL NEOPLASMS 

Among organic lesions which obstruct the breath-road, 
the most frequent, after abnormalities of the nasal septum, 
are new growths of several kinds, which occur within the 
nose. Nasal polypi (Fig. 38) are most common and they 
present a great variety in size, consistency and locality, while 
nearly always showing some uniformity in their shape which 




Fig. 38. — Nasal polypi: three in left nostril. 

is that of an ovoid body attached by a pedicle to the base, 
from which it springs. This suspended mass moves freely as 
far as the surrounding cavity permits. It presents a rather 
glossy surface of bluish-gray color and, to the sense of touch, 
is pulpy, so that dents are easily made by the finger or the 
probe. There is little difficulty in diagnosis. This ovoid body 
is traversed by fibers of connective tissue and their interspaces 
are filled with a semisolid substance whose constituents exhibit 

62 



NASAL NEOPLASMS 63 

much variety in different specimens. Myxomatous material, 
derived from modified and degenerated elements of the mucous 
membrane, is a chief component and with it are found 
mucous and serous glandules, calcareous matter, broken-down 
blood corpuscles and fragments of dead bone; these things 
are present in variable proportions and one or more may be 
absent in particular instances. Small blood vessels ramify 
through the polyp's epithelial covering and a few traverse 
the stroma; but the vascularity is usually slight, an impor- 
tant fact in connection with its surgical treatment. 

The etiology of the polypus has given rise to many dis- 
cussions in which every factor in its morbid anatomy and 
histologic pathology has been considered at length. One 
group of investigators has held that this neoplasm is a myx- 
oma, or mucoid tumor, and originates in a sacculation of the 
mucous membrane, gradually enlarging and becoming filled 
with the diverse elements constituting its contents. The 
increase at the distal end is faster than at the base, hence the 
mass assumes a pedunculated shape. The inflammatory con- 
ditions near the growth, the involvement of some of the sinuses 
and the necrosis of bony structures, often observed as coin- 
cident phenomena, are regarded as sequels of the obstruction 
which the polypus causes to respiration, drainage and the 
circulation of the blood, impeding the nutrition of the tissues 
and lowering their vitality. Another group has considered 
the polypus not as the cause, but as the result of the other 
conditions. According to this view, the bone disease is usu- 
ally primary and, where this is not present, the etiological re- 
sponsibility falls upon sinusitis in some form. The polypus 
is merely a manifestation of an effort to repair the damage 
already done, but the process of growth is abnormal and, di- 
verted from its proper course, results in a morbid neoplasm 
which makes matters worse instead of better. 

There are three facts, admitted by everyone, which furnish 
a sufficient basis for treatment, and their bearing and cogency 
are the same, whether we accept the first theory, prefer the 



64 NOSE, THROAT AND EAR 

second, or leave the question open. These three facts are 
(i) the polypus itself; (2) the concomitant lesions, such as 
necrosis, sinusitis, etc., and (3) the lesson clearly taught by 
clinical experience that removal of the growth is very likely 
to be followed by recurrence, unless the concomitant lesions 
also have been cured. This is one among many instances 
where, most fortunately, the adoption of efficient therapeutic 
measures need not wait upon the adjudication of mooted 
points in etiology. 

The most common site of a polypus is the surface of the 
middle turbinated body, or the contiguous portion of the 
fossa, but it may spring from the mucous membrane in any 
part of the nose. The growth may be single or multiple and 
sometimes more than a score of polypi exist simultaneously; 
in such a case, of course, nearly all are quite small. Occa- 
sionally a group of diminutive growths, ranged near each other, 
resembles a group of papillomata, as the pedicles are absent, 
but the character of the inclosed material classifies these masses 
as polypoid. The symptoms caused by a single polypus of 
large size, or by a number of small ones, are those of obstruction 
and its consequences. One nostril may be almost closed, so 
that the natural secretions are held back, except when mo- 
mentarily released by sneezing or violent blowing of the 
nose. The degeneration of these secretions makes them 
offensive and they irritate the mucosa, setting up a sub-acute 
inflammation with a muco-purulent discharge. The patient 
suffers from itching, burning sensations within the nose, 
and mouth-breathing brings on dryness of the pharynx and 
hyperemia. The resonance of the voice is lessened by en- 
croachment on natural cavities which produce this quality, 
and the sense of smell is at first affected by cutting off access 
to its nerves, on one side, and, later, it may be permanently 
injured by atrophic changes. Vaso-motor rhinitis and asthma 
sometimes join this train of morbid effects. When the growth 
continues for a long time without check, it may disfigure 
the nose externally, making it much broader on one side and 



NASAL NEOPLASMS 



65 




producing the appearance of flattening, although the height 
of the osseous bridge is not really altered. This deformity is 
the so-called "frog face," a familiar sight in some countries 
and at one time quite common here. It is now a rare thing 
in this country and the change is due to the 
popularization of rhinology, leading to the re- 
moval of the causes producing the disfigure- 
ment. 

The treatment of polypi by astringents, 
caustics, or any other half-way measures, is 
not only futile but injurious. Thorough ex- 
tirpation is the only rational course, and this 
will generally effect a cure. When the growth 
is of some size and has a distinct pedicle, the 
best instrument for its removal is the cold 
wire snare. Instrument makers have for sale 
many forms, but the essential features are a 
steel loop, which should be made of piano wire, 
designated as number 5, a biperf orate canula 
through which the ends of the wire pass, a 
handle, and a screw, by which the wire may be 
drawn backward toward the handle, slowly 
diminishing the size of the loop until it dis- 
appears entirely, the wire having gradually 
cut through any body which the loop encircled 
(see Fig. 39). 

When the polypus springs from the middle 
turbinal, the most common site, it is ablated 
in this way. Ischaemia and anaesthesia having 
been produced in both the neoplasm and the 
adjacent tissues by the application of epineph- 
rin chloride and cocaine (or novocain), the 
wire snare is introduced through a large nasal speculum, with 
its loop in the vertical plane, until the tip of the loop passes 
beyond the growth. The lower side of the loop is then ro- 
tated under the bulbous part of the polypus which it now en- 

5 




Fig. 39.— The 
cold wire snare, 
combining the es- 
sential features; 
wire loop, biperfo- 
rate canula, handle 
and screw for 
shortening wire. 



66 NOSE, THROAT AND EAR 

circles. The size of the loop is then slightly lessened by a 
turn of the screw and it is passed over the pedicle to its base. 
The loop is then progressively constricted, care being taken 
that, while one of the surgeon's hands controls the screw, the 
other hand keeps the loop firmly pressed against the base of 
the growth, until the wire begins to cut into the pedicle. If 
this precaution is neglected the incision may be too far out 
and a part of the pedicle may be left attached to the turbinal. 

As the wire bites into the tissue, the rotation of the screw 
should be very slow so as to get the haemostatic effect of gradual 
strangulation. After the pedicle has been divided, the wire 
snare is withdrawn and the dissevered polypus taken out with 
dressing forceps. The bleeding which follows this operation is 
usually slight, both on account of the character of the neoplasm 
and because the vessels have been occluded by the strangulation. 
If continued oozing requires a styptic, the most satisfactory is 
sodium perborate. The moistened cotton tip of an applicator 
is dipped into the powdered salt and carries it to the bleeding 
spot. As soon as the perborate comes in contact with the 
serum of the blood, it generates dioxide of hydrogen. As this 
is in the nascient state and of full strength, it acts more ener- 
getically than the dilute acid solutions of this unstable com- 
pound, which are ordinarily dispensed. The haemic albumen is 
quickly coagulated and the clot has a firm consistence which 
may usually be trusted to seal up the capillary orifices. In 
rare cases packing of the wound for a short time may be 
required. 

The wire snare can be used for polypectomy in other localities, 
provided its loop can be applied so as to encircle the pedicular 
part of the growth, but it is not adapted to the ablation of 
very small polypi, nor those which are sessile and resemble 
papillomata. These are best removed with biting forceps or 
with the curette. In all cases of polypectomy the raw surface 
left by the operation must be carefully examined both visually 
and with a blunt probe, to ascertain the condition of the under- 
lying structures, osseous or cartilaginous and if any necrosis 



NASAL NEOPLASMS 



67 



be discovered, all sequestra must be removed and the resulting 
cavities treated aseptically until healing takes place. If this 
procedure is neglected, a recurrence of the polypi is very prob- 
able, a sequel disappointing to the patient and injurious to the 
reputation of the operator. Moreover, no radical and perma- 
nent cure can be expected unless the bones, or the parts of 
them remaining after the arrest of the disease, are restored to 
their normal vascularity and are healthy in all other respects. 

Fibromata (Fig. 40) are tumors 
composed of connective tissue and 
growing very slowly. They are 
classed with benign neoplasms; 
but have a tendency, under cer- 
tain conditions, to undergo a 
malignant degeneration. On this 
account, they should be removed 
as soon as possible after their 
discovery. Nasal fibromata are 
rare and most of those reported 
have been situated near the pos- 
terior end of the middle turbinal, 
on the border of the naso-pharynx. 
To avoid haemorrhage they should 
be extirpated with the cold wire 
snare, when the tumor can be en- 
gaged in its loop. When this is 
impracticable, cutting forceps and the curette may be em- 
ployed. 

A haematoma (Fig. 41) is a tumor composed of blood and it 
is sometimes found upon the nasal septum. When a highly 
vascular tissue is deprived of the support of adjoining structures, 
the blood vessels become greatly engorged and the pressure 
against their walls may result in rupture with haemorrhage, or 
in a great distension of their coats. This enlargement produces 
a tumor of dark color, thin, tense wall, and liquid contents, 
fluctuating to the touch. When, in the submucous resection 




Fig. 40. — Nasal fibroma originat- 
ing in left fossa. Such a growth is 
usually removed with the cold wire 
snare. (Stout.) 



68 NOSE, THROAT AND EAR 

of the septum, the removal of the cartilaginous central plate 
leaves the membranes on each side without their habitual 
support, a haematoma may be formed. This development of a 
postoperative haematoma can nearly always be v prevented by 
giving adequate support to the soft tissues which are subjected 
to unaccustomed strain. The Simpson-Bernay nasal tampons 
should be introduced into the nostrils and allowed to remain 
until the agglutination of the intraseptal surfaces converts the 
two walls into one, equalizing the pressure of the blood (see 
Chapter IV, Nasal Septum). 

If this precaution has not been taken, or the patient has 
removed the tampons prematurely, as sometimes happens, and 




b 



Fig. 41. — Haematoma springing from nasal septum. 

the blood tumor has formed, then the sack must be cut open, 
all its contents thoroughly removed and the cavity washed out 
with normal salt solution. Afterward the lateral supports can 
be introduced, so as to bring intraseptal surfaces together and 
promote their union. Sometimes haematomata are due to 
traumatism. In such cases the accumulated blood must be 
evacuated, the sack cleansed and its walls brought into apposi- 
tion by pressure with pads of sterile gauze, cotton, or other suit- 
able substances. The exact technique of applying this pressure 
depends upon the conditions present in each particular case. 



NASAL NEOPLASMS 69 

It seems a small matter, but requires knowledge and skill, 
both surgical and mechanical. To make enough pressure, and 
not too much ; to apply the supporting dressing in such a way 
that it will not be loosened by respiratory acts, nor by the cus- 
tomary movements of the patient; these and similar things 
distinguish the competent surgeon from the bungler and they 
make a very great difference in the result of treatment. 

The skin covering the nose may be the seat of furuncles and 
abscesses, due to infection of the dermal follicles, just as in any 
other part of the integument. Their symptoms and treatment 
are nearly the same as when located elsewhere, but on account 
of the undulating surface and continual movement of the alae 
nasi, the outlet of pus in this region, whether spontaneous or by 
incision, is more apt to leave a scar than at other points; an 
unfortunate circumstance, as a cicatrix, which would be of no 
consequence upon some part covered by clothing, may cause 
much dissatisfaction when in such a conspicuous position. 
For this reason, it is well to abort furuncles, if possible, and in 
the papular stage their development may often be arrested by 
rubbing into the skin a salve made of equal parts of mercurial 
ointment and the extract of ■ belladonna, and then making 
pressure with a compress held in place by adhesive strips or by 
a bandage encircling the head on the plane of the occiput. If 
this treatment succeeds, resolution will begin in eight or ten 
hours; so the dressing may be put on at night and removed in 
the. morning. 

Intranasal abscesses are nearly always caused by the de- 
composition of coagulated blood in a hematoma. As the clot 
degenerates, purulent effusion occurs through a fissure in the 
wall. Treatment consists in evacuating the contents of the sac, 
cleansing it with an alkaline solution and sustaining the flabby 
walls by introducing on their exterior tampons or other 
mechanical supports. If treatment has been neglected, until 
the formation of a pyogenic membrane, drainage may be re- 
quired for several days, until the internal surface is covered by 
granulations. 



70 NOSE, THROAT AND EAR 

Malignant disease, in the form of either sarcoma, or carci- 
noma, is the worst of intranasal neoplasms. It occurs in ad- 
vanced life and its pathological character, symptomatology 
and nearly hopeless prognosis, are similar here to what is pre- 
sented in other regions of the body. If the tumor is thoroughly 
eradicated, at a very early period of its growth, there is hope 
that there may be a long interval before its recurrence, and 
hence an early diagnosis is of paramount importance. Sar- 
coma usually grows in the anterior part of the nasal cavities 
and can be seen from the vestibule as a red mass, resembling 
raw beef, and bleeding upon the slightest pressure with the 
probe; these characteristics differentiate it from a polypus or 
a haematoma. Carcinoma makes its appearance further back 
and to the eye resembles a polypus, but it is very dense and hard 
and, touched by the probe, imparts a sensation wholly different 
from that given by the pulpy, yielding polypus. Malignant 
tumors should be operated on, as soon as possible after the 
diagnosis has been made, and the operation should be thorough- 
going so as to remove every particle of diseased tissue. An 
external incision is usually required to secure room for the most 
radical extirpation. Fortunately these growths within the 
nose are rare. A most thorough search in the surgical literature 
of all countries was made twelve years ago by some rhinologists 
in. New York and every reported case of either sarcoma or of 
carcinoma affecting the nose was noted. The total number 
was less than 200. 



CHAPTER VI 
NASAL EXTRANEA 

Foreign bodies in the nose constitute another class of ob- 
structions to the breath-road. The name is applied only to 
bodies of some size and does not cover micro-organisms. These 
are just as extraneous as any others but, in conformity with 
established usage, they will be classed as nasal infections, 
which are not primarily obstacles to respiration, but may pro- 
duce lesions causing obstruction. A unilateral nasal discharge 
usually indicates the presence of a foreign body, or sinusitis. 
In children sinusitis is rare; while foreign bodies are found 
frequently. 

The best division of nasal extranea is into (i) the motile 
and (2) the impacted. The first group includes nearly all 
whose entrance has been recent; for impaction is generally due 
to tissue growth, which incarcerates the intruding body, and 
this requires considerable time. All living insects and parasites 
visible to the naked eye are obviously motile and of recent 
introduction. Impacted bodies are sometimes securely hidden 
and may remain for years quite forgotten, until some accident 
discloses their presence. 

Splinters, metallic fragments, sand and other substances 
traumatically forced into the nose, either through the vestibule 
or the ruptured walls, require no consideration here; as their 
prompt removal is included as part of the treatment of the 
traumatism. Motile extranea are most frequently introduced 
at the promptings of an abnormal desire manifested by the 
insane, the feeble-minded and morbid children, who make the 
nasal vestibule a receptacle for buttons, coins, beans, peas, 
lead shot, balls of masticated paper, fragments of chewing gum 
and other articles. Sometimes children, who do this, are 



72 XOSE, THROAT AND EAR 

bright enough mentally; but are obsessed with a pernicious 
curiosity, which leads them to use all parts of their bodies for 
experimental research. With such children an efficient prophy- 
lactic is the punitive discipline, far too much neglected in our 
time. Most of the articles put into the vestibule drop out 
again; but occasionally one slips backward into the fossa and 
moves from place to place until it either reaches the naso- 
pharynx and falls into the throat, or is arrested by some 
constriction and remains fixed. It is then likely to obstruct 
respiration and to excite inflammation at the point where it 
lodges, bringing on pain, a muco-purulent discharge and some- 
times swelling of one side of the nose. The symptoms attract 
parental attention and at last the child makes a reluctant con- 
fession. It must be said that, if the handiwork of the youthful 
experimenter were brought to the rhinologist directly, it would 
be easy to dislodge the extraneum; for at this time, it is usually 
quite accessible; but there is an intervening stage, when 
maternal solicitude and ignorance have free course; snuff is 
given to excite sneezing, there is violent blowing of the nose, 
the toothpick, hairpin and glove-buttoner are plied indus- 
triously, often starting a profuse epistaxis. The doctor is not 
sought until blood has been shed and, by that time, the case 
has become one of real difficulty, with the foreign body harder 
to reach and more firmly held. 

The surgeon's first effort is to secure from the patient as 
good a description of the object as possible. Often the task is 
easy and the doctor gets a truthful, accurate story from the 
child who told his mother nothing but garbled falsehoods. Of 
course, no such diagnostic help can be expected from the 
insane or feeble-minded. Having gained an idea of the 
intruding body, one can judge of the number of situations it 
may occupy, e.g., a cherry stone will not be found in the 
antrum of Highmore because the ostium maxillare is not nearly 
large enough to admit it. The examination should be deliber- 
ately made with the nasal speculum and blunt-pointed probe 
and, when there is much soreness and swelling, as there usually 



NASAL EXTRANEA 73 

is, in consequence of the injudicious measures already taken, 
cocaine and epinephrin chloride should be applied to obtund 
sensation, to secure ischsemia and to get more room for inspec- 
tion. As this is a case where these drugs are used once for all, 
there is surely no need for timidity in employing them. Many 
a surgeon is depreciated as less intelligent and less skillful than 
another, simply because that other made a roomy and anaes- 
thetic field for his operation. If other means fail to discover 
the foreign body, the x-ray must be employed. It is most 
helpful in case of metals or other substances of great density 
and these constitute the majority. Removal should be in 
accord with a principle of some importance, viz : that, whenever 
possible, the extraneum should be withdrawn through the 
same passage by which it entered. This withdrawal may be 
effected with a probe bent at right angles near the point, by a 
loop of copper wire, or by forceps with dentated, corrugated, or 
cup-shaped terminals. Neat work depends upon anatomical 
knowledge and mechanical ingenuity and deftness. In rare 
instances, pushing into the naso-pharynx may be the most 
practicable course of removal. This involves danger of drop- 
ping into the larynx; which is much lessened by placing the 
patient upon the back with the head slightly lower than the 
shoulders. Sometimes a foreign body goes into a crevice 
easily enough, but refuses to come out, though it is hard to tell 
what holds it. A slight incision, a mere nick, may release it, 
and it is better to make such a cut than to procrastinate with 
continued traction and other manipulations. When the 
offending body is out of the way, all the symptoms rapidly 
disappear and no treatment is commonly required, except one 
or two irrigations with an alkaline wash and a few sprayings 
with camphorated liquid petrolatum, five grains to the ounce. 

Insects, either in the winged or larval form, sometimes enter 
the nose and there are reports of the deposit and development 
of their ova in the sinuses. Such accidents really belong to 
tropical medicine. A1J. such intruders are certainly destroyed 
by chloroform, and this, mixed with liquid petrolatum (1:8) 



74 NOSE, THROAT AND EAR 

can be used as a spray, care being taken to prevent injurious 
inhalation, by injecting only a little at a time. 

After the parasites are killed, the nose should be thoroughly 
cleansed by irrigation. 

When the presence of an impacted body is suspected, search 
for it should be made in the same manner as for one of recent 
introduction and in this case the x-rays prove of especial value; 
for the long-hidden object is nearly always of a dense character 
and has also been covered by calcareous matter, gradually 
deposited upon its surface. These encysted bodies look some- 
what like vesical calculi and have been called rhinoliths. The 
extraction of such an object may require some time and a 
general anaesthetic may be needed. The route by which re- 
moval is accomplished depends on the conditions of each case. 
Preference is given to the natural nasal passages, so as to avoid 
the danger of external scars; but if the mass cannot be taken 
out in this way, then an incision must be made from outside; 
for we dare not leave the foreign body, after it has begun to give 
trouble. However long it may have been harmless, it will not 
resume a quiescent state, after morbid activity is manifested. 
Often the cicatrix following removal through the nasal walls is 
so small, as to attract little notice. Whatever the operation, 
haemorrhage is usually slight, as the encysted body has been 
walled off by fibrous tissue. The emptied cavity should be 
treated antiseptically and continuously drained, until it is 
obliterated by granulation. 



CHAPTER VII 
RHINITIS 

Rhinitis is the general term signifying inflammation of 
the intranasal mucous membrane and includes the different 
forms, such as acute, chronic, suppurative, vaso-motor, and 
the types manifested in the different localities, the passage- 
ways and the contiguous cavities, or sinuses (sinusitis). In 
all places the phenomena are similar with modifications caused 
by different conditions of accessibility, of ventilation and of 
drainage, between a canal open at both ends and a chamber 
with only one outlet. The obstructions, considered in former 
chapters, are connected with inflammation by a causal rela- 
tionship which is reciprocal. They are often an important 
factor in bringing on attacks of inflammation and, conversely, 
such attacks, if of long continuance, or frequent recurrence, 
may produce structural changes of an obstructive character. 

A large proportion of the diseases affecting not only the nose, 
but all other regions of the body, are of an inflammatory 
type and suggest a fundamental question: What is inflamma- 
tion? Elaborate consideration of the answers to this ques- 
tion belongs to those studies, which the reader has pursued 
before taking up a speciality; but there are a few principles 
so essential to clear thinking upon our present subject that 
they must be briefly reviewed. The answer to the basic 
question may be given from either one of two standpoints, 
(i) We may endeavor to explain the etiology and pathology 
of the process; (2) we may describe the symptoms and physical 
signs. This second answer is important diagnostically and 
clinically. It is by rational symptoms and by physical mani- 
festations that morbid processes are identified, nine times in 
ten; the tenth case being the exception, when diagnostic 

75 



76 NOSE, THROAT AXD EAR 

certainty requires further investigation. The symptoms and 
signs are valuable clinically because they indicate the treat* 
ment advised by a long succession of therapeutists, who have 
expressed their opinions in the terms of symptomatology. 
This answer is also easy to give. The ancient physicians, who 
were most accurate observers, drew word-pictures of the 
inflammatory process of almost photographic fidelity. Their 
hypothetical etiology, sometimes interesting, sometimes al- 
most grotesque, has long been obsolete; but their symptoma- 
tology has stood the test of the centuries. They gave us that 
classic aphorism intended to fix in the memory four leading 
characteristics of the process; calor, rubor, tumor, dolor, and 
daily experience attests the truth that heat, redness, swelling 
and pain, are the most constant signs of inflammation. 

The other answer, which logically has precedence, views the 
question from the standpoints of etiology and pathology. 
It is far more uncertain. Many theories have been accepted 
upon the authority, or arguments, of distinguished men; only 
to be discarded on the advice of others equally eminent. The 
actual phenomena look to us just as they looked to Hippocrates, 
but their interpretation seems to be as varied as the meanings 
of a Delphic oracle. The theory most widely accepted, at 
present, regards inflammation as a defensive warfare against 
invading microbes. The leukocytes destroy the pathogenic 
germs and are stimulated to this action by the opsonins. Over- 
action may do harm; but the process is usually conservative 
and should be encouraged up to the point of destroying all the 
invaders and removing the cell detritus resulting from the 
conflict. This theory directly contradicts the former doctrine 
that inflammation, where mild or severe, was a harmful process, 
which it was our duty to antagonize. 

It might be thought that such a revolutionary change 
would have brought about a reversal of all the therapeutic 
measures previously used. Fortunately nothing of the kind 
occurred. The profession had too much common sense to 
discard remedies of well-proved value because of changed 



RHINITIS 77 

opinions in pathology. The clinicians and laboratorians 
have come to an agreement by the simple expedient of at- 
tributing to the remedies a new modus operandi. Then thera- 
peutic measures remain the same, but it is now said that, 
instead of antagonizing inflammation, they really augment 
it. This method of accommodating both fact and theory is 
well illustrated by the present view of counter-irritation. 
From days of old, it was common to apply a mustard plaster 
over the site of a deep-seated inflammation. Rubefaction, 
perhaps vesication, took place. The patient was greatly 
benefited. That was the fact. Our predecessors explained 
the improvement by saying that the inflammation, which 
had been working serious mischief inside the body, had been 
drawn to the surface, where it was comparatively harmless. 
The rubefaction, etc., were taken as proofs of this metastasis. 
We also apply the sinapism and observe good results, but 
we say that it acts by increasing the beneficent inflammatory 
process; it attracts more blood, bearing more leukocytes to 
the contest, and also transporting their auxiliary opsonins. 
We regard the rubefaction, etc., as evidences of hyperaemia 
on the surface and also beneath it. It is worth remarking 
that either of these explanations, or any other, is quite satis- 
factory to the patient, so long as he recovers. The rational 
course of the physician is plain. If he has a remedy, of whose 
value he is sure, he should learn its method of action, if he 
can; but even without such knowledge both reason and con- 
science require him to employ it, until he discovers some- 
thing better. New remedies suggested by theoretical con- 
siderations are subjects for experiment; but they have no 
place in therapeutics till approved by clinical experience. 

These matters have been considered in this chapter, because 
it deals with the first of the inflammatory diseases to be con- 
sidered. The observations apply to inflammations within 
the nose; but are equally pertinent to those of other regions; 
for diversities in structure, position and function, do not alter 
the validity of the principles laid down. 



78 NOSE, THROAT AND EAR 

Acute rhinitis is in our climate a very common, perhaps 
the most common disease. Its synonyms are coryza, catarrh 
of the nose, cold in the head, and they indicate the popular 
belief that it is due to the action of cold, an opinion that has 
given origin to the very common phrase, "taking cold," 
which, though sometimes used in other senses, generally 
means contracting coryza. This idea of causation voiced in 
colloquial speech was formerly shared by the profession, 
but modern bacteriology includes this disease in the category 
of those produced by germs. It is certain that in the nasal 
discharges microbes of many species are often found, but 
which particular one is responsible for rhinitis has not been 
determined. Indeed, any bacteria floating in the air may 
enter the nostrils and, becoming entangled in the vicid secre- 
tions, be apprehended on the spot, although guiltless of any 
part in producing the inflammation. There can be no ques- 
tion that acute rhinitis is more prevalent in the winter than 
in the summer, nor that it is especially frequent in our country, 
where marked changes in temperature occur so suddenly. 
Cold, particularly when associated with humidity and when 
quickly succeeding warm weather, is in some way connected 
with its production. Both ideas of its etiology are recognized 
in the view which regards micro-organisms as the cause and 
cold with dampness as a condition most favorable to the 
operation of that cause. 

Rhinitis both in its acute and chronic forms is to some degree 
an occupational disease. Ballet girls who, while scantily clad 
and freely perspiring from muscular exertion, are exposed to 
chilling drafts from the rear of the stage are frequent sufferers. 
Those using the sand blast are often attacked, although they 
seek protection by covering their faces with screens. Smoke, 
dust and other mechanical irritants may act as exciting causes 
and the same is true of corrosive chemicals, such as the fumes 
of many acids. Among predisposing causes are classed the 
gouty diathesis and various dyscrasias, which lower vitality and 
diminish the organism's power of resistance; but the most 



RHINITIS 79 

important predisposing factors are adenoids and abnormalities 
of the nasal septum, which cause such encroachment upon the 
breath-road and such hindrance to proper drainage that the 
various functions are performed only while there exist favor- 
able conditions — there is no lee-way to neutralize unfavor- 
able influences. Therefore, when the environment becomes 
injurious there is congestion, atresia and a train of morbid 
phenomena. The man with an obstructing septum contracts 
severe rhinitis from hostile conditions which do no apparent 
harm to the man whose septum is normal. 




Fig. 42. — Interior view of the right wall of the nose, in a normal condition, 
showing the turbinals, whose structure renders them liable to a high degree of 
congestion. 



The symptoms of acute rhinitis range themselves in three 
stages. In the first, the mucosa is dry and tense, its color 
assumes a deeper shade and there is marked congestion, which 
particularly affects the turbinals on account of their spongy 
structure (Fig. 42). This congestion hinders or entirely stops 
nasal respiration and the patient is forced to breathe through 
the mouth. There is much discomfort, frequent sneezing and 



80 NOSE, THROAT AND EAR 

sometimes frontal headache. A common symptom is general 
chilliness and the patient says, "I feel I am catching cold," 
while the clinical thermometer may show no change in tem- 
perature, or even indicate a slight elevation. After a few 
hours there appears a watery discharge, "running at the nose," 
which consists of serum, leaking from the capillaries, mixed 
with much mucin from the glandules. The turgid condition 
of the mucosa is relieved by this outflow and the patient is 
more comfortable, except for the disagreeable dripping of the 
viscid liquid. After a variable time, often two or three days, the 
discharge becomes much thicker and its color changes to straw 
yellow. This is the third stage, characterized by the outflow 
of pus, due to the peripedesis of the leukocytes. This purulent 
discharge continues freely for a day or two and then diminishes. 
As its quantity grows less, it produces peculiar sensations, which 
lead the patient to expel it by blowing the nose; there is some 
evaporation and the residuum becomes semi-solid in con- 
sistence. At this point the attack may terminate, or it may 
last longer and the drying muco-pus form thin crusts. The 
disease usually passes through these stages, "runs its course," 
in a week's time, but the duration may be less if the patient is 
removed from the influence of the exciting cause. The disease 
may be aborted during the first stage, the inflammation ending 
by resolution; or it may stop while the discharge is muco- 
serous, before any pus appears. These cures are sometimes 
spontaneous and sometimes the result of treatment. 

Acute rhinitis, if it is confined to the nasal passages and is 
not greatly prolonged, commonly ends in complete recovery 
and does no permanent harm. If, however, there be extensive 
involvement of the sinuses, or if the middle ear be affected, its 
sequels may be much more serious. A prolongation of the 
attack generally signifies some underlying organic trouble. 
Tedious attacks, indeed, are often found to be exacerbations of 
a chronic affection rather than truly acute seizures. 

In treating this disease, the physician is forcibly reminded of 
the paradoxical saying that "the best patients get the worst 



RHINITIS 8 1 

treatment." In many acute inflammations remarkable good 
is done by detergent and sedative measures. A warm bath 
followed by moderate purgation and a mild diuretic, a milk 
and water diet, with rest in bed and entire physical and mental 
inaction — these things both mitigate and shorten the attack in 
a surprising way. Such treatment is readily accepted by the 
idle novel reader, the lounger in bar-rooms and the hospital 
sponger — useless individuals well content to take things easy 
and let others provide for them. They make admirable re- 
coveries; but the forceful people, whose lives and health are 
most valuable to the community, are often antagonistic to this 
method. Unless their diseases are absolutely disabling, they 
try to keep on their feet and will not interrupt their work. 
In consequence, they frequently suffer permanent injury from 
an illness which should have caused no lasting damage. 
Men of this sort are greatly benefited by sojourn at foreign 
spas, or sanatoria, where they rapidly improve, because they 
are cut off from mental and physical strain and make a business 
of getting well by assiduously following their physicians' 
directions. At home, they get only that part of the treatment 
which can be given to one still actively occupied, and the 
doctor must bear that fact in mind and adapt his measures, as 
far as possible, to ambulatory conditions. It may not be 
practicable to enforce a milk diet, but stimulating foods can be 
excluded and alcohol and tobacco forbidden. The sexual 
functions have a marked influence upon the nasal mucosa and, 
while it is inflamed, should be as far as possible in abeyance. 
Tea and coffee are usually objectionable. One or more free 
movements of the bowels should be secured, at the start, by 
administering at half-hour intervals, until they operate, tablets 
each of which contains a fourth of a grain of calomel and one 
grain of sodium bicarbonate. This is advantageously followed 
every two hours by a capsule containing hexamethylenamin 
(urotropin), gr. jss and acetyl-salicylic acid (aspirin), gr. v. 

Sedative and ischaemic effects should be produced by spray 
from an atomizer. The best vehicle is the normal salt solution, 
6 



82 NOSE, THROAT AND EAR 

sodii chloridi o j ad aquae destillatae Oj, which should be quite 
warm when used. The addition of ten grains of cocaine hy- 
drochlorate to an ounce of this excipient makes a two per cent, 
solution, which is the proper strength for spraying. Epinephrin 
chloride should have the proportion of i to 10,000. A solu- 
tion of nearly this composition is made by adding a fluidram 
of the usual preparation of epinephrin chloride (1 : 1000) to a 
fluidounce of the salt solution. Menthol and camphor prove 
valuable for topical application. Five grains of each should 
be dissolved in an ounce of liquid petrolatum and the com- 
pound painted upon the mucous membrane with a cotton- 
tipped applicator. 

These measures serve to modify the course of the disease, 
rendering it milder and shorter and less liable to produce 
injurious sequels. The accumulation of discharges impels the 
patient to blow his nose very often and he should be cautioned 
to do this gently, for violence may drive muco-purulent fluid, 
which has trickled back into the naso-pharynx, through the 
lower orifice of the Eustachian tube and induce inflammation 
of the middle ear, a complication much worse than the primary 
disease. 

When acute rhinitis merges into the chronic form, there are 
usually organic changes and the disease assumes either the 
hypertrophic or atrophic type; but aside from these, there is a 
peculiar chronic variety which is very prevalent among 
children in our climate. Its special characteristic is a profuse 
and persistent muco-purulent discharge, which excoriates the 
vestibule, the alae nasi and upper lip, and they become covered 
with crusts of repulsive appearance interspersed with raw, 
granulating fissures, from which the scabs have been picked. 
This is so marked a feature and is so common among lads of 
from four to ten years that it has given rise to a vulgar, but 
expressive, nick-name for a small boy who is untidy and ill- 
kept. The superabundant pyorrhoea appears to arise from the 
great vascularity and mutability of the tissues still in the stage 
of active growth and in which the proliferation and metabolism 



RHINITIS 83 

of cells are very rapid. These conditions accentuate the in- 
flammatory processes. 

This disease is much more common among boys than among 
girls, perhaps on account of their rougher life and their neglect 
to keep the nose clean. Among exciting causes are ill-venti- 
lated and overheated rooms, from which the boy emerges to 
freezing temperature and the handling of snow; wet feet due to 
broken shoes ; unsuitable clothing, often too thick ; indigestible 
food hastily swallowed and, among the poor, deficient in nutri- 
tive value. 

The treatment comprises correction of the bad hygienic 
conditions, regulation of the bowels and cleanliness of the nose. 
The turgescence of the turbinals, which is a marked feature in 
most cases (see Fig. 42), is well reduced by anointing their 
mucous membrane with the glycerite of tannin on a cotton- 
tipped applicator. The granulating surface left by the removal 
of crusts, scabs and dirt from the vestibule should be treated 
with the ointment of the yellow oxide of mercury. A safe and 
efficient lotion for use at home, three or four times daily, is 
made by adding to four fluidounces of the normal salt solution 
eight drops of the tincture of iodine. This must be prepared 
each day, as it deteriorates if kept. It is to be slowly and care- 
fully injected with a soft, all-rubber, ear syringe, the head 
being inclined forward so that the liquid may not run back 
into the naso-pharynx. A great deal of good can be accom- 
plished by this treatment perseveringly followed, and it is a 
serious mistake to neglect this rhinitis of childhood, as is so 
often done; for, when long continued, it not only injures the 
nasal tissues, but does harm to the surrounding organs, render- 
ing them more susceptible to infections in later life. 

Hypertrophic rhinitis, also called hyperplastic, is char- 
acterized by thickening of the soft tissues, especially those 
covering the lower turbinate bone. It is generally the sequence 
of many recurrent acute attacks, particularly when these have 
been "left to nature" or improperly treated. The hyper- 
trophy to some extent interferes with respiration and, when a 



84 NOSE, THROAT AND EAR 

temporary congestion makes it worse, there may be closure 
of the breath-road on one or both sides. The symptoms are 
those of obstruction, more or less complete, with mouth 
breathing and the laryngeal, bronchial and even pulmonary 
irritations which follow it. There is also nasal discomfort and 
frequently some change in the vocal intonation, which loses the 
resonance produced in the naso-pharyngeal vault. Left to 
itself, the disease usually pursues a course of gradual extension, 
with intervals when it is stationary. Spontaneous cure is not 
to be expected. The first step in treatment is to thoroughly 
cleanse the nose by gentle irrigation with the normal salt 
solution; the next is to remedy as completely as possible any 
catarrhal conditions which may be present, by employing the 
measures recommended in acute rhinitis and given in detail in 
its consideration. In fact, catarrhal conditions are often 
presented, for the patient is very apt to apply to the specialist 
at a time when he feels worse than usual, because his chronic 
affection is aggravated by coryza. 

Having gone this far, we reach a dividing of the ways and 
must decide whether the hypertrophied tissues shall be partially 
removed or an effort made to secure their absorption by means 
of the lymphatics. Some years ago, the galvanocautery was 
widely used, under the belief that the resulting eschar destroyed 
part of the superfluous tissue and that the cicatrix, having 
been produced by a burn, would progressively contract, making 
pressure upon the underlying blood vessels and permanently 
inhibiting the recurrence of congestion and turgescence. This 
procedure was adopted by many surgeons, because it appeared 
to be a rational and ingenious application of existing knowledge 
regarding the cicatrices following burns; but experience soon 
showed that it was liable to a very serious objection, not fore- 
seen by those who introduced it. When the cautery was used 
upon the middle turbinal, the marked inflammatory reaction 
not infrequently extended to the membranes of the brain and 
produced meningitis. As there is no method for warding off 
this danger, it has now become a maxim of rhinology that the 



RHINITIS 



85 



galvanocautery is prohibited in operations upon the middle 
turbinal. No blame attaches to those who devised the opera- 
tion, for the risk of meningitis could not have been predicted: 
it is altogether a matter of post factum knowledge. The intro- 
duction, acceptance and disuse of the cautery illustrate a 
truth which must always be remembered: that no operation, 
however promising it seems, however logically its principle is 




Fig. 43. — Removal of anterior part of middle turbinal. The incision across 
the front end is made with scissors. Through this is introduced the wire loop 
to encircle the part to be removed. The dotted line indicates the segment of 
the loop concealed from view -behind the hypertrophied mass. 



deduced from former knowledge, can gain full approval and 
confidence, until both its value and its safety have been proved 
by long and wide experience. 

When hypertrophies upon the middle turbinal are of such 
shape that they may be encircled by a loop, they may be re- 
moved with the cold wire snare as depicted in Fig. 43, or by 
cutting forceps. Ridges and rugosities can be reduced with the 
curette. These instruments can be used also upon the inferior 
turbinal, and in its treatment the galvanocautery appears to 



86 NOSE, THROAT AND EAR 

be safe and hence may be employed when cicatricial contraction 
is desired. 

Cauterization with chemicals produces a milder reaction 
than the galvanocautery and is not apt to set up meningitis, 
hence it is suitable for use upon the middle turbinal and else- 
where. Chromic acid is often employed, either by lightly 
drawing a fused bead across the surface, or by the submucous 
method with probe and canula. The trichloracetic acid also 
may be used for cauterization and its chemical action upon the 
tissues is similar to that of chromic acid. As compared with 
incisions by sharp instruments, these caustics produce more 
inflammation, requiring longer time for healing. On the other 
hand, as they act by desiccating the tissues, they do not cause 
haemorrhage. The surgeon must choose the plan of treatment 
best suited to the patient, taking into account the local lesions 
and also the constitutional conditions of the individual. In all 
cases he should, as a preliminary, secure local anaesthesia and 
make the nasal fossa as roomy and as clean as possible by con- 
tracting the turbinal tissues (cocaine or epinephrin chloride, 
or both) and washing away all secretions and discharges with 
the normal salt solution, that of D obeli, or some other lotion 
of alkaline character. All these washes act better when warm. 

The nonoperative treatment has for its object the deple- 
tion of the hypertrophied tissues by absorption of part of their 
substance through the lymphatics. This is a strictly physio- 
logical process, capable of stimulation by certain chemicals, 
which act either topically or through deep-seated glands, 
perhaps by modifying the control of histogenetic processes 
by the adrenal chain of the so-called ductless glands. This 
process of absorption is necessarily slow, and does not satisfy 
those who demand an immediate cure; but there are patients 
who prefer prolonged medicinal treatment to any shorter 
method which involves cutting or burning. After looking at 
the matter from all sides, the surgeon may decide upon the 
plan for slow reduction: its results may prove highly gratify- 
ing; if it fails, the operative measures are in reserve. 



RHINITIS 8 



The remedies used are those which have astringent and 
eliminative qualities. Boulton's solution, which was intro- 
duced more than twenty-five years ago, has the following 
formula : 

1$. Tinct. iodini comp Ttlxx 

Acidi carbol. (pure) Tfl.vj 

Glycerini fl. 5 vij 

Aquas dest fl. 5 v. M. 

This is sprayed by an atomizer three or four times a week, 
but is not entrusted to the patient for use at home. Dis- 
tilled extract of witch-hazel, diluted with an equal quantity 
of water, is employed with similar frequency and under similar 
restrictions. Camphor and menthol, which are most efficient 
when conjoined, should be applied to the hypertrophied tissues 
and to the mucosa of contiguous parts. From five to ten 
grains of each remedy are added to a fluidounce of the officinal 
petrolatum liquidum and the unctuous liquid used with a 
cotton-tipped applicator. 

Chronic rhinitis not unfrequently causes an inflammation 
of the lachrymo-nasal duct, which when long continued pro- 
duces stenosis, preventing the drainage of the tears from 
the lachrymal sac into the lower meatus of the nose. This 
is a very unfortunate sequel of the disease, inflicting, in addi- 
tion to habitual discomfort, a great deal of annoyance and 
vexation. Deprived of their normal outlet, the tears overflow 
the orbital margin at the inner canthus, simulating con- 
tinued weeping upon the affected side, and running down 
over the cheek irritate the skin, even macerating it in persons 
whose integument is specially tender. Often to this overflow, 
termed epiphora, there supervenes suppuration of the lachry- 
mal sac with exudation of pus, habitually appearing as a dirty 
yellow globule at the canthus, replaced almost as soon as 
wiped away. 

Patients are so much distressed by this morbid condition 
that they will endure and even solicit radical orbital opera- 
tions, in hope of relief. In many instances, ophthalmologists 



88 NOSE, THROAT AND EAR 

to get a "dry eye" have enucleated both the lachrymal sac 
and lachrymal gland, thus destroying a healthy organ, for 
the gland is rarely diseased, and abolishing a normal func- 
tion on account of a morbid condition outside the orbit. Such 
operations are now rarely performed. It is recognized that 
nine-tenths of the cases of epiphora originate in the nose and 
it is here, not in the orbit, that remedial work should be done. 
The procedure which came into vogue, under the influence 
of this idea, was the restoration of patulency to the closed 
lachrymo-nasal duct. Its orbital aperture was enlarged and 
efforts made to restore its lumen to an adequate size, by the 
successive passage of a graduated series of distending probes. 
Some success attended this treatment, especially where the 
duct was obstructed but not occluded. It proved inefficient 
where there were inflammatory adhesions of long standing 
and, in all cases, it was painful, tedious and uncertain in its 
results. 

Impressed by these objections to the method of dilation, 
several operators determined to abandon the effort to enter 
the duct from the orbit and to start at the other end, where it 
and its inclosing bony canal terminate in the inferior nasal 
meatus. This method speedily won favor with surgeons on 
the European continent and, while all had a common pur- 
pose, there was much diversity in the technique adopted by 
different rhinologists. The various plans which had proved 
reasonably successful were finally epitomized and analyzed 
by Onodi in an elaborate thesis, which has proved the ground- 
work for most subsequent studies of the subject. 

Sidney Yankauer worked for three years as a follower of 
the method advocated by Onodi, which may be regarded as 
a composite, embracing those features of various operations 
which have best stood the test of time. With this experience 
as a guide, he devised the operation which bears his name 
and which, during the two years it has been before the pro- 
fession, has won the approval of many American rhinologists. 
A descriptive outline follows: 



The patient receives a hypodermic injection of morphia 
or of morphia-scopolamin, the object being to make sure 
that general sensation is somewhat obtimded independent 
of the effect of cocaine, because there is sometimes difficulty 
in administering the local anaesthetic at the stage of the pro- 
cedure when it is most needed. He is placed on the operating 
table in the semi-recumbent position, the operator standing 
beside him and face to face: a solution of cocaine (10 per 
cent.) and epinephrin Q^ooo) is applied if the canal is occluded; 
if it is pervious, the anaesthetic liquid may be introduced to 
its interior through the lower orifice. When much time is 
consumed, additional anaesthetic applications may be^re- 
quired. To get as much room as possible in the nostril of 
the affected side, the septum is drawn away and held by a 
retractor, during the operation. The mucous membrane 
of the outer nasal wall in the area including the lachrymo-nasal 
canal is divided by a vertical incision on the border of this 
area, which is nearest the nasal crest, and by two horizontal 
incisions extending backward from the upper and lower ends 
of the vertical incision; it is then separated from the sub- 
jacent structures by an elevator and forms a rectangular 
flap which is turned backward and carefully guarded from 
injury. The next step is to open up the osseous canal through 
its entire length. This is done with bone-cutting forceps or 
a guarded chisel, care being taken not to break into the max- 
illary sinus. By clearing away the osseous fragments the 
membranous duct is exposed to view. With suitable scissors 
or knife this duct is slit open from below upward, all the 
way from its lower orifice up to and including the lachrymal 
sac. All strictures are divided; the venous plexus surround- 
ing the canal is destroyed; any accumulated pus cleaned away 
and the entire passageway, converted into an open sulcus, 
thoroughly cleansed. Finally the flap of mucous membrane 
is restored to its place and its union with the subjacent surface 
promoted by careful packing of the nostril with sterile gauze. 
When satisfactory union takes place and there is no excessive 



90 NOSE, THROAT AXD EAR 

inflammatory reaction, the end result of the procedure is a 
tube with an osseous wall on its outer side and a wall of mucous 
membrane toward the septum. This tube has a lumen some- 
what larger than the original duct and furnishes ample lach- 
rymal drainage. 

Yankauer's operation was brought before the profession 
only two years ago and, of course, a longer period is necessary 
for such experience as will accurately determine its place in 
orbito-nasal therapeutics; but there is hope that it may prove 
a curative procedure in a morbid condition, whose treatment 
by other methods has been very disappointing. 

Hypertrophies of the posterior part of the lower turbinal 
have peculiar features due to their position on the margin 
of the postnasal cavity. They can extend backward without 
meeting any resistance and hence often attain great size, 
causing obstruction to respiration and interfering with the 
functions of the Eustachian tubes. As they rest upon the 
upper surface of the velum palati, they frequently embarrass 
its movements. By anterior rhinoscopy, through dilated 
nasal fossae, such an hypertrophy appears as a tumor rising 
and falling with the motions of the velum. Posterior rhin- 
oscopy shows a granulated or lobular mass attached to the 
end of the lower turbinal and perhaps large enough to hide 
the nasal septum. Such a growth gives rise to a muco-puru- 
lent discharge like that observed in chronic rhinitis. Two 
hypertrophies of this kind are shown in Fig. 44, a reproduc- 
tion of the image appearing in the postnasal mirror held in 
the naso-pharynx. The growth should be extirpated, under 
cocaine anaesthesia, by introducing the cold wire snare through 
the anterior nares and encircling the tumor in its loop. Twenty 
or thirty minutes should be allowed for gradual strangulation, 
as a precaution against haemorrhage. The postnasal mirror 
or a finger in the naso-pharynx will aid in adjusting the snare. 
This operation is illustrated in Fig. 45. 

The reduction of hypertrophies necessitates the separa- 
tion and removal of redundant cells from the tissues and the 



RHINITIS 91 

remedy which renders this service better than any other, is 
iodine. Just how it acts is still a mooted question; but there 




Fig. 44. — Two hypertrophic tumors upon the posterior ends of the lower tur- 
binate, as shown by the image in the posterior rhinoscopic mirror. 




Fig. 45. — Removal of a hypertrophic tumor from the posterior end of the 
lower turbinal, with the cold wire snare. 



has long been abundant proof of its power to cause catabasis 
of the cells in tumefactions, without such degeneration as 



Q2 NOSE, THROAT AND EAR 

would render them toxic. It appears simply to dislodge them 
and to start their emigration through the lymphatic vessels. 

A solution of iodine adapted to the skin requires much 
dilution for use upon the mucous membrane. If too strong, 
it devitalizes the epithelum and the dead cells prove a barrier 
to absorption. Some irritation is to be expected; it simply 
shows that the drug is taking effect, but this reaction must 
not be severe, or the purpose in view will be defeated, and 
this is a mistake very often made. The physician's skill is 
manifested in so regulating the strength of his solution, that 
the iodine molecules will penetrate through the soft tissues 
and start the cellular migration. The three formulae follow- 
ing have been accredited by long experience; the weakest 
solution should always be used at the start; then, if the mem- 
brane seems insensitive, the second should be employed. 
It is a very efficient remedy and as strong as is ever indicated 
in the hypertrophic form of the disease. The third solu- 
tion may be needed in some intractable cases of atrophic 
rhinitis which have resisted other treatment. 

No. i. 1$. Iodini gr. viij 

Potass, iodidi gr. xxiv • 

Glycerini fl. oviss. M. 

No. 2. 1$. Iodini gr. xij 

Potass iodidi gr. xxxvj 

Glycerini fl. Sviss. M. 

No. 3. 1$. Iodini gr. xvj 

Potass iodidi gr. xlviij 

Glycerini fl. Sviss. M. 

It will be observed that in all these prescriptions the amount 
of the vehicle, glycerine, is the same, viz: six and one-half 
fluidrams, also that the potassium iodide, added chiefly 
to promote solubility, is thrice the amount of the iodine. 
This, the essential thing, varies from eight grains to twelve 
and sixteen, making the preparations respectively nearly two 
per cent., three per cent, and four per cent, solutions of iodine 
in glycerine. The technique is the same in each case. Sensa- 



RHINITIS 93 

tion is rendered dull by applying a two per cent, solution 
of cocaine hydrochlorate to the hypertrophied tissues, which 
are then lightly coated with the iodinized glycerine. The 
cotton pledget upon the applicator must not be wet enough 
to drip and must not cause undue pressure. 

As the elimination of the superfluous cells depends upon 
their absorption by the lymphatics, sufficient time must be 
allowed for such action. The patient should be seen three 
times a week, so that the application may be repeated upon 
alternate days. When this treatment is followed patiently 
and persistently, a large proportion of the cases are cured. 

Atrophic rhinitis, also called dry rhinitis and ozaena, has 
two well-marked characteristics, by which it is easily recog- 
nized; the formation of large crusts composed of cellular 
debris of various kinds undergoing putrefactive changes and a 
repulsive odor disseminated at every expiratory act. This 
evil smell has a peculiarly nauseating effect upon some healthy 
people, so that if they come into contact with a patient, emesis 
is unavoidable. The patient is often unconscious of the odor, 
because the disease is apt to destroy the terminals of the 
olfactory nerves and thus abolish the sense of smell. Although 
the repulsive character of ozaena undoubtedly depends upon 
the decay of animal matter, it has some peculiar qualities which 
are sui generis and this has led many to think that a microbe 
adds to the putrefactive gases an additional substance not yet 
isolated. The patient's knowledge that he is repulsive to 
others often causes him keen mental distress and a priori it 
would seem that the inhalation of tainted air would soon 
produce most serious autointoxication. It is one of the 
enigmas of pathology that many persons are for years rendered 
repulsive by this symptom and yet maintain a state of com- 
paratively good constitutional health. 

While the sclerotic variety of rhinitis, which causes little 
odor, is a sequel of the hypertrophic form, the atrophic variety 
very often follows the purulent rhinitis of childhood. The 
etiological factors in the atrophic type of the disease are not 



94 NOSE, THROAT AND EAR 



certainly determined. Some believe that a micro-organism, the 
bacillus fcetidus, is the real cause. Others attribute the disorder 
to venous engorgement due to cardiac weakness; to the effects 
of intractable sinusitis and to neglect of proper treatment for 
rhinitis in its other forms. Whatever the cause may be, it 
leads to atrophic changes in the mucosa and submucosa, with 
destruction of many of the glandules, and the loss of their secre- 
tions produces the harsh dryness of the passages, which is a well- 
marked symptom. The ciliated epithelium disappears and its 
place is taken by one of squamous type, while some of the 
destroyed cellular layer is gradually replaced by a network of 
fibrous tissue of low vitality. Occasionally, there is atrophy 
of one or more of the turbinate bones. The indications for 
treatment are to dislodge and remove the crusts and then to 
thoroughly cleanse the intranasal surfaces and counteract the 
ozasnal odor by irrigating with a detergent, alkaline solution. 
Crusts hard to detach can be disintegrated with hydrogen 
peroxide, used a few drops at a time, by means of a cotton- 
tipped applicator. It cannot be applied freely because the 
active effervescence, produced by its reaction with pus, might 
drive some extremely septic material into the sinuses. As a 
deodorizer, a lotion of one grain of potassium permanganate in 
half a pint of water will be found very efficient. The fossa? 
should be irrigated with this solution by using the soft, all- 
rubber, ear syringe. The most valuable treatment to follow 
the cleansing process is the graded application of iodine in 
glycerine, as detailed in a former paragraph. This often 
checks the atrophic process and there may even be some repair 
of tissue. The iodine appears to exert its strong antiseptic 
powers upon the putrefaction and also to induce catabasis of 
the fibrous elements, which are accumulating to form connective 
tissue. Their removal gives opportunity for the regeneration 
of the normal cellular structure of the parts. For home treat- 
ment, the patient may use, with the all-rubber syringe, a 
wash made by adding half a fluidram of the tincture of iodine 
to a pint of the normal salt solution. 



RHINITIS 95 

Vaso-motor rhinitis, autumnal catarrh, rose cold, hay fever, 
are synonyms designating a peculiar form of intranasal 
inflammation with great vaso-motor relaxation, so that the 
blood vessels are turgid and there is oedema, soreness, itching 
and profuse leakage of serum. The conjunctiva is affected in 
a similar way, presenting a bright red congested aspect, and 
there is copious lacrimation. The sensory nerves share in the 
disorder, becoming so hypersesthetic that irritation of the most 
trivial kind will excite violent and persistent sneezing. A 
psychic element is frequently present, manifesting itself in a 
restlessness and irascibility out of proportion to the physical 
discomfort, great as that is. Persons, whose self-control is 
habitual, may during an attack display an excitability almost 
hysterical. Another sign of psychic involvement is the fact 
that the symptoms, at least some of them, may be produced by 
subjective sensations. In sufferers from rose cold, the neural 
phenomena are excited by inhaling the fragrance of a rose. 
Some of these patients will sneeze violently if a rose (which they 
think natural) is brought close to their nostrils, although the 
flower may be artificial and devoid of any odor. 

Heredity and sedentary pursuits are considered predisposing 
causes. The chief exciting cause of hay fever, in the opinion 
of most authorities, is the pollen of flowering plants, floating in 
the atmosphere and reaching the nasal mucosa in the act of 
inspiration. The disease is most prevalent in the latter half of 
August, when this pollen is most abundant, and gradually 
subsides with the passing of that season. Rose cold occurs 
when roses are in bloom — the end of May and the month of 
June — and is explained in a similar way. There are, however, 
some cases of the disease for which this theory will not account, 
as they take place during the months when vegetable life is 
dormant. They are at present unexplained. There is no 
disease in which the success of prophylaxis is better established 
than in hay fever; that there are a few exceptions does not 
invalidate this statement, and prophylaxis is what should 
be advised whenever it is practicable. The sandy seacoast, 



96 NOSE, THROAT AND EAR 

where flowering plants do not thrive, and mountains at an 
altitude too great for them, are exempt from the malady, 
except when it is imported from other localities. This is true 
also of elevated plateaus, whose vegetation is chiefly pines and 
other coniferous trees. To the list should be added the open 
ocean with its air free from any contamination whatever. 
Hay fever usually recurs with clock-like regularity upon the 
same date each year. If the patient will anticipate that date 
by a day or two and go to some exempt locality, sojourning 
there until the end of the period which, in his case, is the usual 
time of duration, he will escape the attack. He will remain 
immune as long as he persists in this course and sometimes 
longer, for several instances have been reported where men, 
after numerous annual absences, were detained one year at 
home but remained well, the susceptibility to the disease 
having been outlived. Many business men, with much prac- 
tical wisdom, arrange their annual holiday to cover their hay 
fever period, going either to the White Mountains, or to some 
barren stretch of shore or spending the time aboard ship upon 
the high seas. They thus avoid the depression of the annual 
attack and escape the asthma, which is the malady's most 
serious sequel. 

The plan is an admirable one, but the majority have not the 
means to adopt it fully, though much may be done by utilizing 
the customary two weeks' vacation, spending it at some one 
of the numerous islands upon the Atlantic Coast, many of 
which are exempt and can also be visited at small cost. 

When prophylaxis cannot be made available, recourse must 
be had to those remedies, whose efficiency has been clinically 
proved, and used by a master of the art; these will effect a 
great deal in mitigating the symptoms and in preventing com- 
plications, but not much in shortening the course of the disease. 
Inspired by the success of the diphtheritic antitoxin, Prof. 
Dunbar of Hamburg administered to horses a substance de- 
rived from the pollen of many plants, and then from the equine 
blood produced a serum called "pollantin" which was given 



RHINITIS 97 

both as a preventive and a cure for hay fever, and was applied 
to the intranasal mucosa and to the conjunctiva, as well as 
hypodermically injected. 

This attempt to find a serum treatment, being in accord with 
the trend of therapeutic investigation, excited considerable 
interest and elicited some hopeful reports; but the evidence 
in favor of pollantin is far too scanty to win it a place among 
accepted remedies and it remains a subject for experimentation. 
The constitutional disturbance in hay fever may be lessened 
by the judicious administration of saline laxatives and diuretics, 
so as to eliminate any waste products detained in the system 
and to get the tranquilizing effect of detergent treatment. If 
sleep is much disturbed, chloral hydrate and the bromides 
should be used in accordance with the established principles of 
general medicine. Epinephrin chloride is a trustworthy stimu- 
lant of vaso-motor contraction, but its effect is so transitory 
when given internally as to greatly abridge its usefulness. In 
the strength of i : 5000, mixed with a two per cent, cocaine solution, 
it should be topically applied by saturating cotton pledgets and 
inserting them over the inferior turbinal where the swelling 
is often excessive. In a short time marked shrinkage occurs 
and the obstruction to respiration is much lessened. It is true 
the relief is only temporary, but it gives an interval for the 
ventilation and drainage of the sinuses, it encourages the 
patient, and it makes room for irrigation. This should be 
effected with an alkaline lotion, like DobelPs or the normal salt 
solution. The soft, all-rubber syringe may be employed for 
this procedure which, if carefully carried out and repeated 
several times daily, does much to mitigate the symptoms and 
renders the patient far less uncomfortable. 

After the acute attack has subsided, careful search should 
be made for any nasal lesion that may have proved a causative 
factor. Abnormalities of the septum should be corrected, 
hypertrophies of the turbinals reduced and polypi removed. 
Hyperesthetic spots upon the intranasal mucosa should be 
destroyed with chromic acid or the galvanocautery, under 

7 



98 NOSE, THROAT AND EAR 

local anaesthesia. Search should also be made for any con- 
stitutional dyscrasia and, if found, proper treatment should be 
given. In addition, every effort should be made to build up the 
patient's health by the restriction of stimulants and excitants 
and the use of nourishing food, exercise and a hygienic mode of 
life. 



CHAPTER VIII 
NASAL INFECTIONS 

The intranasal tissues, being vascular and sensitive, are apt 
to be affected, more or less, in a great variety of morbid states. 
Some change in their appearance and some disturbance of their 
function enter into the symptom complex of many acute 
diseases and often prove an aid to diagnosis. For example, a 
catarrhal congestion of the nasal mucosa is almost invariably 
present in the first stage of measles and aids in differentiating 
this malady from some others of the exanthematous group. 
Where such manifestations are purely symptomatic and de- 
pendent upon progressive stages of a constitutional disease, 
they belong to the province of general medicine rather than to 
rhinology; therefore, the only infections considered in this 
chapter are those which affect the nose to such a degree as 
to produce real local disease, either functional or organic. 

Influenza, or la grippe, is an acute, infectious fever which 
has been common in the United States for thirty years, some- 
times comparatively quiescent and then breaking out in severe 
epidemics, but never wholly absent. For three decades prior 
to this period it was not seen in this country and had been so 
entirely forgotten that, upon its resurgence, most people thought 
that an absolutely new disease had made its advent, a mistake 
soon corrected by old physicians, who in the middle of the 
nineteenth century had encountered the same malady under 
the name "tyler-grip." The disease is endemic in Russia 
whence, at irregular intervals of time, it spreads over the world 
and then for long periods disappears. The pathogenic organism 
is an extremely minute, nonmotile bacillus, which was found, 
identified and named in 1892. The discovery has not helped 
to explain the malady's curious migrations, nor aided us in 

99 



IOO NOSE, THROAT AND EAR 

prophylaxis or in treatment, which are still empirical. A 
peculiarity of influenza is that the brunt of the attack is some- 
times borne by one organ, sometimes by another, hence there 
have come into use such terms as "nasal grippe," "bronchial 
grippe," "abdominal grippe." 

When the nose is especially affected, the attack begins like a 
severe case of coryza. The catarrhal symptoms are accom- 
panied by a marked rise in temperature, which reaches an 
elevation not explicable by the local inflammation. In spite of 
this pyrexia, the sthenic stage usually seen at the beginning of 
fevers is wholly absent. From the start, there is muscular 
weakness and nervous depression and the asthenia is often very 
pronounced. As inflammation spreads in the nasal chambers, 
frontal headache comes on and often grows severe. To this is 
superadded neuralgic pain in various parts of the head and face, 
a pain whose character is frequently such as to resemble a 
neuritis of one of the cranial nerves. 

The sense of smell is often blunted and may be wholly sus- 
pended. The breath-road is obstructed upon one or both 
sides, because the mucosa has become swollen, and a muco- 
purulent discharge begins to flow from the congested intra- 
nasal tissues. In a short time this discharge is liable to become 
very profuse. 

In a variable time, the symptoms tend to decline, as is the 
case with most acute, infectious inflammations; but the defer- 
vescence in this disease is attended by many irregularities and 
uncertainties. Spontaneous cure is frequent, but it cannot be 
predicted with great confidence and, both as to simultaneous 
complications and as to sequels, influenza is surrounded by an 
atmosphere of doubt. The patient should not be entrusted to 
the curative powers of nature alone, but should have the 
benefit of such therapeutic measures as experience shows to be 
useful additions to the expectant treatment. 

As the nasal inflammation is the local manifestation of a 
constitutional disorder, there is need for both topical and general 
treatment and, since asthenia is a prominent factor, absolute 



NASAL INFECTIONS IOI 

rest is the first thing indicated. The patient should remain 
in bed and should abstain from all mental, as well as physical 
exertion. The more complete the quiescence, the less is the 
tendency to complications. If there is any constipation, 
calomel in hourly doses of a quarter grain together with a grain 
of sodium bicarbonate, should be given, until the bowels are 
freely moved. A mild febrifuge, like the spirit of nitrous ether 
or the solution of ammonium acetate, proves useful; so also does 
the hot foot-bath. If there is insomnia, rive or ten grains of 
Dover's powder should be given at night. In light attacks 
no other medication may be required. When the type is 
severe, acetanilid and the salicylates are often beneficial and I 
have had satisfactory results from the mixture of thirty grains 
of acetanilid with twice that quantity of acetyl salicylic acid, 
ten grains to be administered at intervals of four hours, until 
the symptoms are ameliorated. Occasionally pain and rest- 
lessness are so marked as to call for a hypodermic injection of a 
quarter grain of morphia. It is the concurrent testimony of 
many clinicians that quinine, while not a specific, favorably 
modifies the course of the disease and shortens its duration. 
Except in the very mild cases, this remedy should be ad- 
ministered from the beginning until convalescence, in doses of 
from one to three grains thrice daily, according to the patient's 
susceptibility to its influence, a matter in which there is much 
variation. 

In the local treatment an important indication is to diminish 
the engorgement of the intranasal membranes and so lessen 
the obstruction to respiration and give better opportunity for 
the drainage and ventilation of the sinuses. The best ap- 
plication for this purpose is a solution of cocaine and epinephrin 
chloride and the following formula gives the strength ordinarily 
required: 

1$. Cocaine hydrochlor gr. v 

Liq. epinephrin chloridi fl. 5j 

Normal salt solution q.s. ad. fl. 3j- M- 

A few minims should be sprayed, or dropped, into each nostril 



102 NOSE, THROAT AND EAR 

every three or four hours and, for this purpose, the preparation 
is entrusted to the nurse. Five minutes after the above ap- 
plication, the nasal chambers should be thoroughly irrigated 
with normal salt solution and this should be followed by the 
oleaginous liquid described in the appended formula: 

1$. Camphor, 

Menthol aa gr. v 

Petrolat. liquid fl. 5 j. M. 

This oil should be sprayed into the nostrils with a hand nebu- 
lizer, or it may be applied through the vestibule, drop by drop, 
by means of a rubber top pipette. These successive procedures 
may be expected to secure free nasal respiration and its con- 
comitant drainage and ventilation for a period of from two to 
four hours. In addition, the prevention of accumulations of 
muco-purulent matter and the modification produced by the 
saline fluid tend to protect the sinuses from infection and to 
guard the Eustachian tube from the entrance of septic matter. 
In view of the contagiousness of influenza, the patient should 
be isolated and as its infection is very readily transmitted by 
bodily discharges, these, whether from the nose or elsewhere, 
should be promptly and thoroughly disinfected. 

Diphtheria may attack the internasal membranes either 
primarily, or as a consequence of its development in the throat. 
Here, as elsewhere, it is characterized by the formation of a 
fibrinous exudate, or false membrane, which displaces the 
normal epithelium of the mucosa. This resembles in ap- 
pearance a fragment of worn, frayed linen and has a dirty 
gray color and a peculiar odor, for which there is no descriptive 
name, except "diphtheritic;" but once smelt, it is readily 
remembered. If the pseudo-membrane is raised with a probe, 
it transmits to the hand a sensation as of something tough and 
semi-elastic; and this sensation also is easily recollected. In 
mild cases this membrane may be the only local manifestation. 
When the disease is severe, the involvement of the cervical 
glands and constitutional symptoms clearly indicate the nature 
of the infection. 



NASAL INFECTIONS IO3 

The exciting cause of diphtheria is the Klebs-Loeffler bacillus 
commonly found in great numbers in smears taken from the 
affected membranes. The discovery of this germ and the 
consequent introduction of the diphtheritic antitoxin, wrought 
an entire revolution in the constitutional treatment and so 
greatly reduced the mortality that this malady, once so much 
dreaded, has been shorn of many of its terrors. It is the nearly 
unanimous verdict of the profession that antitoxin should be 
used in every case and that the patient should be isolated until 
the membranes are free from the pathogenic bacilli. These 
sometimes linger after the symptoms have disappeared and 
when the patient not only appears well, but feels himself fully 
restored to health. The danger in these cases is not so much 
that of a possible relapse as of the transmission of the disease. 
The procrastinating germs are quite capable of infecting other 
persons and in them may exhibit typical virulence, although 
they appeared innocuous to their former host. This risk of 
contagion inheres not only in the cases of incomplete con- 
valescence, but in those of a very mild, ambulatory type, where 
constitutional disturbance is extremely slight and the only 
local sign, pointing to diphtheria, is the false membrane. 
Many of the patients, in whom the disease pursues such a 
course, are those having a primary intranasal infection, the 
throat remaining unaffected throughout the attack, and thus 
a mistaken diagnosis of rhinitis is often made. Liability to 
this error is increased by the fact that in the muco-purulent 
rhinitis of childhood we often see a grayish exudate, which 
somewhat resembles the diphtheritic pseudo-membrane. When 
this, which is the most characteristic sign of diphtheria, has 
been simulated and perhaps also located where examination is 
difficult, it is not strange that many mistaken diagnoses have 
been made. Certainty can be reached only by bacteriological 
tests and, in view of the danger of spreading infection above 
noted, such tests should be resorted to whenever there is 
ground for uncertainty. 



104 XOSE, THROAT AND EAR 

Local treatment of the nasal form of diphtheria is an adjuvant 
to constitutional serum therapy and has in view the protection 
of the mucous membrane and its restoration after morbid 
changes. The false membrane should be gently detached and 
the nasal fossse irrigated with a lotion made by adding fifteen 
minims of the tincture of iodine to a pint of the normal salt 
solution. This will often suffice, but when further alterative 
and astringent action is indicated, the powdered thymol-iodide 
(aristol) may be applied to the intranasal mucosa by means of 
an insufflator. 

Syphilitic infection of the nose may present the phenomena 
of any of the malady's three stages: primary, secondary, or 
tertiary. The spirochasta pallida is generally regarded as 
the exciting cause and this germ is believed to be present 
in every case, though its minute size may make it hard to 
find. Persevering search for the protozoan is more important 
in this disease than in most others, because an irrefutable 
diagnosis is frequently a matter of great moment, not only 
for its medical bearings, but also from the social and legal 
points of view. The primary lesion of syphilis is compara- 
tively rare in the nasal region. It is occasionally seen upon the 
mucous membrane near the vestibule and the virus has been 
carried, it is alleged, by an unclean handkerchief, by the roller 
towel suspended in the common wash room of inns and board- 
ing houses and even by the nozzle of a nasal douche, handled 
by unclean fingers. The possibility of a primary lesion must 
be borne in mind, when an intranasal examination discloses 
a sore of unusual appearance. The hard chancre, here as 
elsewhere, shows at the beginning an indurated elevation 
with flat top and a smooth, shiny, red surface. This soon 
breaks down into an ulcer which has marked induration of 
its edges (a pathognomonic sign) and whose center is covered 
with a yellowish-gray patch of disintegrating cells and other 
debris. The submucous infiltration causes swelling, which 
impedes respiration and may produce external bulging upon 
the affected side. There is always enlargement of the cervical 



NASAL INFECTIONS 105 

and submaxillary glands and frequently headache and some 
fever. . 

The chief manifestation in the secondary stage is syphilitic 
coryza. This resembles the nonspecific type and hence its 
true character is frequently not recognized until the advent 
of the tertiary stage with infiltration and necrosis makes 
plain the diagnosis, when it is too late to prevent irreparable 
damage Syphilitic rhinitis' is much more obstinate than 
the simple form and there is more tendency to the oozing of 
blood. When a case is unusually chronic and treatment pro- 
duces little effect, especially when the discharges are hab- 
itually blood stained, the physician should make careful search 
for syphilitic manifestations in other parts of the body and 
for any particulars in the family or individual history which 
may bear upon the etiology. The intractable rhinitis of in- 
fants, the so-called "snuffles," is of syphilitic origin, and nasal 
affections among young children of poor physique when they 
become chronic should always excite suspicion and prompt a 
search for the specific germ. In cases of doubt, recourse should 
be had to the Wassermann and Noguchi reactions for syphilis 
and, as these tests require much skill, the very best labora- 
tory aid should be squght. 

The lesions of tertiary syphilis are those most frequently 
encountered in the nose and they are responsible for those 
extensive destructive changes which sometimes produce shock- 
ing deformities, rendering the sufferer a social pariah, not 
only repulsive but even dangerous, for both miscarriages 
and fcetal monstrosities have been caused- by the sight of a 
noseless man. The first nasal manifestations of tertiary sy- 
philis are often mistaken by patients for nonspecific rhinitis 
and the physician may not see the case until the necrotic 
process has begun. If there is an opportunity for examination 
at the beginning, the true nature of the infection can be in- 
ferred from the character of the discharge, which is blood 
stained and has an unpleasant odor, becoming later on very 
foul. Besides there is more obstruction than in simple rhinitis, 



106 NOSE, THROAT AND EAR 

because the submucous infiltration causes much thickening. 
In a majority of cases, the intranasal sufaces show those soft, 
red, nodular swellings called gummata (Fig. 46). These are 
pathognomonic and mark the beginning of the retrograde 
changes caused by the disease. A gumma breaks down into 
an ulcer, encircled by an indurated border, within which 
is a dark colored mass of pus cells, disintegrating blood cor- 
puscles and other decaying matter giving off a foul odor. The 
process advances through the submucosa till it reaches the 
cartilage or the bone, which become necrotic and fragments 
of which (sequestra) may separate and be spontaneously 
discharged through the nostrils. When the phenomena occur 
in this order the diagnosis presents little difficulty, but there 
are instances in which the disease moves from within out- 
ward, primarily attacking the bone, or cartilage, and break- 
ing through the mucous membrane only after their devitaliza- 
tion. In such cases the collateral symptoms and the anamnesis 
must be reviewed as aids to diagnosis and the finding of the 
pathogenic germ is highly important, as deciding the ques- 
tion affirmatively; but failure to discover it does not always 
justify a negative conclusion. Gummata may distend the 
nasal wall so as to cause an exterior enlargement (Fig. 47). 

The disease most likely to be confounded with tertiary 
syphilis is atrophic rhinitis. In both there is a repulsive 
odor and crusts are formed upon the intranasal mucosa; but 
careful examination develops differences sufficient for diag- 
nosis, even without finding the spirochaeta. In atrophic 
rhinitis the crusts are dry, scaly and of a yellowish or green- 
ish color, while parts of the mucous membrane not yet enveloped 
have a pale, shrunken appearance. When crusts are removed, 
the underlying tissue, either osseous or cartilaginous, shows 
only atrophic changes, such as ischaemia and shrinking. In 
syphilis, the crusts are grumous and colored dark by disin- 
tegrated corpuscles, while blood oozes from cracks in their 
surface. The crusts rarely cover so large a part of the intra- 
nasal area as in the other disease, and the surrounding mucosa 




Fig. 46. — Ulcerating gummata of the nasal septum; a manifestation of syphilis 
in its tertiary stage. 



(Facing page 106 ) 



NASAL INFECTIONS IO7 

is moist, darkly red and swollen, frequently presenting side by 
side all the stages of ulcerative change. Beneath the crusts 
the bone and cartilage, if already involved, show the rough 
irregularities of structure and the perforations which are the 
familiar evidences of necrosis. These differences together with 
signs of syphilis in other parts of the body are usually sufficient 




Fig. 47. — Gummata of the nasal bones causing disfigurement. 

for diagnostic purposes, even without the aid of bacteriology, 
which, as above remarked, should be obtained if possible. 

The topical treatment of syphilitic lesions must be carried 
on in conjunction with the constitutional therapeusis which 
is our main reliance. Mercury and potassium iodide have for 



108 NOSE, THROAT AND EAR 

many years been considered our most trustworthy remedies 
for impressing the whole system, the iodine salt being specially 
useful in the tertiary stage. Recently Prof. Ehrlich's sal- 
varsan (paradiamidodioxyarsenobenzol dihydrochloride) and 
neo-salvarsan which is a modification of the former, have 
been very widely used, but have not rendered the older reme- 
dies obsolete. 

Rapid mercurialization which should be effected as soon 
as the diagnosis has been made, is brought about by daily 
inunction with unguent, hydrarg. oj- The ointment is ap- 
plied successively to the right and left armpit, the groins and 
the loins, one region being used each day of six and the process 
being repeated in the same order. The slightest sign of tender- 
ness of the gums signifies that a constitutional impression has 
been made and the treatment can be interrupted. The sys- 
temic impression can also be made by giving the protiodide 
of mercury in quarter grain doses, three times a day, and add- 
ing daily another fourth of a grain, until the gums indicate 
that the remedy is taking effect. Then the dosage should be 
reduced by one-half and the treatment continued upon that 
basis. 

The administration of iodide of potassium follows, in general, 
the same method. It should be given at first in small doses 
and these should be progressively increased, until there appear 
the first indications of the drug's physiological effect, when the 
quantity should be lessened and afterward regulated by the 
circumstances attending the case. 

The local treatment of gummata, before the ulcerative 
process has begun, is directed to the maintenance of intra- 
nasal cleanliness, so as to cooperate with the constitutional 
remedies, which are acting through the blood. Irrigation with 
an alkaline solution like the normal salt, or Dobell's, fulfills 
this indication. When ulcers have formed, they should be 
cleared of pus and detritus with a detergent lotion and then 
touched with a solution of silver nitrate; a dram to the fluid- 
ounce. In the tertiary stage, all necrosed bone should be 



NASAL INFECTIONS 109 

carefully removed with cutting forceps, after sufficient anaes- 
thesia has been secured with cocaine and epinephrin chloride. 
Spots, where putrefactive action is taking place and foul odors 
are given off, are best treated with thymol-iodide (aristol), the 
powder being applied to them with an insufflator. 

Tuberculosis in the nose is usually secondary to an infection 
of the throat or lungs, but sometimes primary. Its essential 
feature is the tubercle which upon the intranasal surface 
presents the same appearance and runs the same course as 
elsewhere. These nodules commonly appear in groups (granu- 
lomata) and, for a time, give the patient little inconvenience, as 
they are not painful and at this stage cause no discharge. 
Frequently no medical treatment is sought until the ulcerative 
process is established, when there is a muco-purulent discharge, 
together with scabs and crusts near the vestibule and perhaps 
perforation of the septum. The cervical and submaxillary 
glands are involved and there is obstruction to respiration, 
more or less annoying. If a mass of granulomatous tissue 
breaks down, forming a large ulcer, it may look somewhat like 
a sarcoma, but the resemblance is not close and the microscope 
will clear up any doubt. Differential diagnosis from syphilitic 
ulcerations is more difficult. The following distinctions will 
usually prevent error. Tubercular ulcers are much more 
indolent than those of syphilis; they give little or no pain, the 
others are often accompanied by much suffering; the tubercular 
ulcers cause little induration, the surrounding mucosa looks 
almost normal and the discharge has little odor. In all these 
respects, the syphilitic sores present precisely opposite condi- 
tions. Tuberculosis usually attacks the cartilage of the 
septum; syphilis preferably some one or more of the bones. If 
there are cutaneous manifestations simultaneously present, they 
will give aid in the diagnosis, for the tubercular affections of the 
skin have an aspect quite different from the syphiloderms. 

Treatment consists in measures indicated by the constitu- 
tional disease and the hygienic regimen which now plays such 
an important part. Locally, anaesthesia should be induced by 



HO NOSE, THROAT AND EAR 

cocaine and epinephrin chloride and then all diseased tissue 
should be removed by the curette or destroyed by a fifty per 
cent, solution of lactic acid. The granulating surface left by 
these procedures is advantageously treated with thymol- 
iodide (aristol) or by pledgets of iodoform gauze, so applied as 
to exert slight pressure. In some instances, it is best to 
cauterize the whole of the affected surface with the loop of the 
galvanocautery. 



CHAPTER IX 
THE NASAL SINUSES 

The accessary sinuses, a skiagraph of which is shown in Fig. 
48, are cavities with osseous walls, lined by mucous membrane 




Fig. 48. — Skiagraph of the nasal sinuses in a living subject. (Leonard.) 

and having small openings into the nasal fossae. In size and 
shape they exhibit many variations, congenital or develop- 



112 NOSE, THROAT AND EAR 

mental, and sometimes one or more of them may be lacking, 
their absence being discovered only during some operation, 
or even at a necropsy. In view of these facts, anatomical 
statements must be taken with the understanding that they 
refer to what is usual, but by no means universal. According 
to most authors, there are four sinuses ; a fifth is added by some. 
They are named from the bones of which they are concavities, 
frontal, maxillary, sphenoidal and ethmoidal. The first two, 
having outlets into the middle meatus, are called anterior, the 
other two, which open into the superior meatus, posterior. It 
is customary to speak of these cavities in the singular number, as 
we say the frontal sinus, not sinuses, but it must be remembered 
that they exist in pairs and when we reckon their number as four, 
we mean four on each side of the median line. 

The functions of these air chambers are not positively deter- 
mined; physiologists say that they promote the resonance of 
the voice; that they defend the brain against shocks by decreas- 
ing the effect of mechanical force transmitted from the bones of 
the face; that they serve to lessen the weight of the osseous 
framework of the head without impairing its strength. What- 
ever uncertainty may exist as to their physiologic utility, there 
is no doubt whatever regarding the harm they are capable of 
doing. Their mucous lining is continuous with that of the 
nasal passages and inflammation, both catarrhal and infectious, 
readily passes from one to the other. The orifices of the sinuses 
are mostly small and have only enough capacity to provide 
drainage for the normal secretions; when to these are added the 
products of inflammation, the channels of escape are soon 
clogged, become inflamed themselves, and convert the cavity 
into a closed chamber, deprived of drainage and ventilation, 
a nidus for infective, septic and putrefactive processes. Whether 
diseased action begins in the meatus and extends to the 
sinus, or starts in the sinus and hence spreads to the open pas- 
sages, such obstacles are created as make impossible the sanita- 
tion of the nasal region and morbific agents, which would other- 
wise be of little moment, are rendered exceedingly harmful by 



THE NASAL SINUSES 113 

the obstruction that nullifies every effort of the organism to 
cast off pathogenic substances. Here, as in so many other 
instances, it is the obstruction which is by far the worst factor 
in the situation. 1 

The ethmoidal sinus differs from the others in being a 
series of cells occupying small depressions in the ethmoid 
bone; on this account, some recent authors have designated 
it the ethmoidal labyrinth. There is much variation in the 
number and arrangement of these cells; those located posteriorly 
drain into the upper meatus and are by some named the 
posterior ethmoidal sinus, constituting with the sphenoidal 
sinus the "posterior group" of Hajek. The few (two to six) 
cells placed before these, and which are connected with the 
middle meatus are, under this classification, placed together 
with the frontal and maxillary in the "anterior group." 
Writers following this authority add a fifth sinus to the list 
by designating these cells the anterior ethmoidal sinus. 

It is a very significant anatomical fact that the openings 
leading from the middle meatus to the frontal sinus, to the 
maxillary sinus, and to these anterior ethmoidal cells, are all 
near together; all these cavities drain into the infundibulum 
and, if it be affected by disease, the morbid condition very readily 
extends to each of them, so too, obstruction here occludes them 
all. The middle turbinal and the contiguous structures, ex- 
tending from the center of that body through a radius of fifteen 
or twenty millimeters constitutes a nosogenic region (Fig. 49) 
in which occur the first manifestations of many morbid processes, 
that subsequently extend to other parts of the nose, and par- 
ticularly the sinuses. Here is the starting point of nearly all 
cases of sinusitis, except those affections of the maxillary sinus, 
which are of dental origin and in these also permanent relief 

1 It is related that, in a postprandial speech, a distinguished laryngologist 
said, "So continually are we confronted by morbid conditions due to obstruction 
that, as the Roman Senator Cato closed each of his orations with the words, 
'Carthago est delenda!' so I would wish, in every lecture, to put the greatest 
emphasis upon the supremely important dictum, Obstructio est delenda!" 



ii4 



NOSE, THROAT AND EAR 



requires the making and maintaining of a drainage route into 
the middle nasal fossa. 

The etiological fact just stated is the basis for a general plan 
of treating diseases of the sinuses which, though subject to some 
exceptions, hereafter specified, applies to the great majority of 
cases. This plan contemplates procedures of four kinds, pro- 
gressing logically from the slighter to the more radical ; the prin- 
ciple governing, from first to last, being to carry surgical in- 




lf2B 




Fig. 49. — The nosogenic region of the nose. 

terference as far as is necessary, but no further. Expressed in 
the briefest way, the treatment included in the first procedure 
comprises correcting septal deflections and deformities, reduc- 
ing hypertrophies, normalizing tissues which have suffered 
from chronic rhinitis, and taking care that teeth and gums are 
in a healthy condition. In a proportion of cases, this proves 
sufficient and restores the sinuses to a normal state. The sec- 
ond procedure ablates the tissues within the nosogenic area, 
opening up routes for drainage and ventilation. This effects 
many cures. The third method, used where the others have 



THE NASAL SINUSES 115 

failed, cuts through the walls of the sinuses from their intra- 
nasal aspect and thoroughly removes all diseased tissues and 
morbid products. This radical operation is often successful. 
The few cases which have not been amenable to any of the 
foregoing, demand the use of the fourth and ultimate expedient: 
opening of the cavities from the exterior, the final resort of 
rhinological surgery. 

The symptoms, which point to engorgement and obstruction 
in the nosogenic area, are persistent fronto-ocular pain with 
more or less visual disturbance, and marked tenderness, when 
pressure is made upon the lachrymal bone; with these may be 
associated neurasthenia and mental dulness or cloudiness. If 
there is an accumulation of pus in the ethmoid cells and it does 
not find a downward outlet, it may push the adjoining wall of the 
nose toward the septum and a rupture may take place into the 
orbit, giving rise to orbital cellulitis and exophthalmia. If the 
protrusion of the eye is due to this cause, there will be the fluc- 
tuation characteristic of imprisoned pus. From the orbit, 
the purulent accumulation may find its way backward among 
the intracranial membranes and cause meningitis. If the pus 
escapes downward, there results the condition of open em- 
pyema, which is much more frequent than that just described. 
Diagnostically, the presence of pus in the middle meatus would 
indicate that it had come from the anterior ethmoidal cells, 
the frontal sinus, or the maxillary sinus. As the orifices are 
near together, one of the cavities, two, or even all three may 
prove to be pyogenic. The differentiation of the sources de- 
pends upon other signs. If pus appears in the superior meatus, 
it originates in either the sphenoidal sinus or the posterior 
ethmoidal cells. 

In accordance with the fourfold plan of treatment, outlined 
above, the first procedure is to correct any septal deflections, 
remove spurs, ridges and hypertrophic enlargements, in addition 
to thoroughly cleansing the nasal passages. A week or more 
should be allowed to secure the full effect of these measures. 
They may prove all that is necessary; obstacles having been 



Tl6 NOSE, THROAT AND EAR 

removed, the natural reparative forces may accomplish the 
cure. If this does not occur, the work already done paves the 
way for the second procedure, the ablation of the tissues within 
the nosogenic region. 

An instrument well suited to this operation is the ethmoid 
knife (Fig. 50) which has two flat blades continuous with shanks 
fitting into a common handle, which diverges from them at an 
angle of 100 degrees. The blades have the shape of long quadri- 
laterals and are so ground that, when lying before one, side by 
side, their backs are in contact and the edge of one presents to^ 
the right hand and of the other to the left hand. About eight 
millimeters from the end, each blade is bent at a right angle; the 
result being that the incision which the blade makes under the 
force of pressure from back to edge (without traction) has the 



i 



-<2> 



MEYROWITZ 




Fig. 50. — Ballenger's ethmo-turbinate knives. 

form of a letter L. If the operation is to be performed upon the 
left side, as illustrated by Fig. 51, the surgeon fixes in the handle 
the blade whose edge is toward his right hand, then after 
local anaesthesia has been induced and the left nostril distended 
by a self-retaining speculum, he introduces the blade with its 
back toward the septum and advances it along the sulcus of the 
middle meatus until its bent extremity comes in contact with 
the sphenoid bone, at the posterior boundary of the space. 
When the knife is in this position, its handle extends across the 
right cheek in a line nearly horizontal and a little above the 
plane of the lips. The blade is now pressed against the tissues 
confronting its edge, its longer segment entering at the lower 
margin of the middle turbinal and the upright terminal seg- 



THE NASAL SINUSES 117 

ment cutting the ethmoid cells free from their attachment to 
the surface of the sphenoid. The incision of the cell walls often 
elicits a peculiar crepitant sound. In directing the knife, the 
surgeon uses carefully modulated force and an oscillating move- 
ment. After detachment at bottom and rear has been effected, 
the handle is revolved through an arc of ninety degrees, to a 
perpendicular position in front of the chin; this movement ro- 
tates the blade, turning its edge upward toward the ridge of the 




Fig. 51. — Operation upon the nosogenic region in the left nostril. The handle 
of the knife describes an arc of 90° from A to B and another of equal length from 
B toC. 



nose; a vibratory cutting motion brings the blade through the 
tissues joining the excised mass to the outer nasal wall, as shown 
in Fig. 52. Then the handle describes another arc of ninety 
degrees and comes to rest horizontally across the left cheek; this 
final rotation brings the long segment of the blade on top of the 
detached body and the short segment, pointing downward, 
directly behind it. The knife is now withdrawn, bringing 
with it, en masse, the middle turbinal, the ethmoid cells and all 



NOSE, THROAT AND EAR 



morbid products accumulated in the nosogenic region. Fig. 
53 depicts a mass removed by this procedure. The operation 
upon the right side is performed with the other blade of the 




Fig. 52. — The stage of the nosogenic region operation, when the knife handle is 
nearly perpendicular in front of the chin. The right nostril is shown in this 
figure. 




^tf"- 



Fig. 53. — Morbid mass removed from the nosogenic region. It includes the 
hypertrophied middle turbinal, the ethmoid labyrinth, in a pyaemic condition, 
and polypoid growths. This mass had exerted so much pressure upon the nasal 
wall as to cause the deformity termed "frog face." 

ethmoid knife and is, in all respects, the converse of that just 
described. 

When the ethmoid knife has severed all attachments, the 



THE NASAL SINUSES II9 

whole morbid mass may be withdrawn as the instrument comes 
out of the nose, a very neat and satisfactory result. If this is 
prevented by some strands of uncut tissue, they should be 
localized with a blunt probe and then severed with a guarded 
bistoury or a blunt hook, sharpened upon the concave side. 
When the mass has been wholly dissevered, it is carefully with- 
drawn with dressing forceps. The resulting cavity should now 
be thoroughly inspected and any shreds or fragments of dis- 
eased tissue removed with the curette, scissors, or biting for- 
ceps. If bleeding is not profuse, it can be controlled by sodium 
perborate carried to oozing spots upon a cotton-tipped applica- 
tor. This is often sufficient, but where capillaries of some size 
have been severed, the styptic salt may be washed away before 
a clot forms, and the haemorrhage continue; when this happens, 
the cavity should be packed with a long strip of iodoform 
gauze in multiple folds, leaving a free end by which the fabric 
may be withdrawn when no longer needed. The packing 
should be removed as soon as it can be dispensed with, inside 
of twenty-four hours, if possible, for prolonged sealing up of 
the intranasal cavities is always attended with the risk of 
infection and meningitis. During this first day, the patient 
must remain in bed, in a condition of physical and mental 
quietude. Afterward, the cavity left by the operation must 
each day be cleansed with a warm (no° to 115 F.) antiseptic 
solution and insufflated with thymol-iodide powder, until the 
raw surfaces heal by granulation. If exuberant granulations ap- 
pear, they must be reduced by one or more applications of a 
twelve per cent, solution of silver nitrate or by fused chromic 
acid. The treatment should be pursued faithfully and patiently, 
so as to secure from the operation in the nosogenic area the best 
results of which it is capable. Such a large proportion of sinus 
diseases are curable by this operation that no detail should be 
omitted, which may contribute to its success, and it must be re- 
membered that, if it fails, our only alternatives are operations 
causing more serious laceration of the intranasal structures, or 
those external incisions which may lead to disfigurement, all 



120 NOSE, THROAT AND EAR 

of these involving more danger than attends the conservative 
procedure which has just been described. 

When, as sometimes occurs, a purulent accumulation in 
the ethmoid cells points into the orbit, it is necessary to pro- 
ceed from the outside by making a curvilinear incision through 
the eyebrow, at the root of the nose, taking a direction forward 
and downward, separating the soft parts from the bone, then, 
while these tissues are held back by retractors, to search for 
the opening through which the pus has invaded the orbit. 
When this has been found, it should be enlarged by a curette, or 
small chisel, so as to make a passageway down to the ethmoid 
cells, the course of the excavation being downward and out- 
ward. When the diseased cells are reached, they must be 
broken up and the detritus carefully removed through the 
artificial channel. This is kept open until its walls are cov- 
ered by healthy granulations, when it and also the superciliary 
incision are closed under aseptic precautions. 

The maxillary sinus, called also the antrum; or the antrum 
of Highmore; is the largest of the accessary cavities of the 
nose and occupies a nearly central position in the superior 
maxillary bone. It is somewhat conical in shape, the apex 
being at the malar bone and the base at the outer wall of the 
nose, at the top, it is bounded by the orbital plate; in front 
by the facial plate; below by the alveolar process, and be- 
hind by the zygomatic surface. The antrum has four ana- 
tomical peculiarities, which greatly influence the diseased proc- 
esses to which it is liable, (i) In most places its walls are 
exceedingly thin and, although osseous, somewhat flexible; 
so that under the pressure of imprisoned liquid they become 
convex, bulging upward into the orbit; and laterally into the 
nose, or through the cheek. (2) Its only drainage is through 
a narrow passage terminating in the ostium maxillare, which 
discharges into the inf undibulum ; the opening of this pas- 
sage is near the roof of the sinus so that when the head is 
erect no liquid escapes by gravity unless the antrum is nearly 
full. (3) The infraorbital nerve traverses the inner surface 



THE NASAL SINUSES 121 

of a segment of the sinus wall, being usually inclosed in a 
canal, but quite often running along an open furrow, so 
that the nerve trunk comes into direct contact with any 
liquid which fills the sinus. When this liquid is septic pus, 
the nerve is infected and gives rise to intense pain; though 
this pain is not referred by the sufferer to the antrum, but to 
the regions in which the nerve terminals are distributed, 
especially the teeth, orbit and forehead. This erroneous 
idea of the locality where the pain originates has led to many 
serious errors in diagnosis and, as a consequence, to treat- 
ment both futile and injurious. (4) The roots of three of the 
upper teeth, the second bicuspid and the first and second 
molars, sometimes others also, extend into the antrum. These 
intruding fangs may be enveloped in bony tissue, or in the 
mucous membrane; but not infrequently they are quite bare 
and disease of any sort affecting them possesses every facility 
for spreading through the interior of the sinus. Such trans- 
mission is believed to be responsible for fully twenty per cent, 
of antrum maladies. 

Maxillary sinusitis may, at the start, cause few symptoms. 
The sensations of fullness, weight and discomfort, in one side 
of the face may attract attention; or may be disregarded, 
especially by people whose thoughts are much occupied and 
who pay little heed to sensory impressions. If the infraorbital 
nerve be involved, there may be intense pain in the eye and 
forehead and severe toothache, but, with this exception, 
suffering is not often great so long as drainage continues 
through the ostium maxillare. When this outlet is closed, 
there supervene those symptoms which are associated with the 
incarceration of pus; the sense of weight and a dragging pain, 
with local heat and some constitutional fever; later on anorexia, 
thirst and general malaise. Unless there be an outlet for the 
purulent accumulation, either spontaneous, or surgical, ab- 
sorption may bring about systemic toxaemia. Among physical 
signs, the bulging toward the orbit, the nose, or cheek, already 
referred to, is pathognomonic, but it takes place only when the 



NOSE, THROAT AND EAR 



disease has made much headway. When rhinitis is synchro- 
nously present, the nasal discharges give little diagnostic help 
and none, of course, after the ostium maxillare has been 
occluded, but a unilateral discharge of pus, especially if the 
quantity is greater when the patient lies upon the unaffected 
side with the head low, hints that the fluid comes from the 
antrum and this probability is increased if scrutiny with the 
nasal speculum shows that the pus accumulates in the middle 
nasal meatus. 

Transillumination sometimes proves of much aid in making 
the diagnosis. This procedure is quite simple, but requires 
facilities not always available. The patient sits in an erect 
posture and holds in his mouth a properly guarded and insulated 




Fig. 54. — Coakley's sinus illuminator. 

glass tube or bulb containing a loop, which can be rendered 
incandescent by an electric current placed under the surgeon's 
control. The room is then made entirely dark and the electric 
current turned on. As the tissues of the face including antrum 
walls are to some degree translucent, they become partially 
illuminated and, when in a normal condition, transmit many 
rays and the cheeks are suffused with a peculiar glow. If, 
however, the antrum on one side is filled with pus, the rays are 
intercepted and the cheek on that side remains dark. (Fig. 54 
shows one of the illuminators in common use.) 

When a positive diagnosis of maxillary sinusitis has been 
made, its cure is to be sought by employing the already de- 
scribed procedures, which culminate in the removal of the dis- 
eased tissues within the nosogenic region and by the treatment 
properly following this operation, draining and irrigating the 



THE NASAL SINUSES 1 23 

antrum through the ostium maxillare. For the latter purpose 
use is made of the normal salt solution (warm) followed by a 
lotion containing five grains of zinc chloride in a fluidounce of 
sterile water. 

If, at the end of two or three weeks, we are disappointed in 
securing a marked improvement, it will be necessary to decide 
whether our efforts are nullified by some concealed cause of 
dental origin. I say, concealed cause, for any obvious disease 
of the teeth would have already received attention; because 
such disease clearly belongs to the group of morbid conditions, 
which called for correction at an earlier stage of the fourfold 
plan of treatment herein advised. But a dental trouble, which 
is the real etiological factor, may be hidden. Caries may have 
damaged the enamel and dentine of one of the upper molars; 
the resulting detritus may have been removed and the cavity 
filled with a mineral substitute, which has satisfied all caleidic 
requirements and the dentist's task may have been considered 
finished, and yet there may remain hidden some septic particle, 
capable, under excitation, of infecting the antrum. When 
such excitation takes place, sinusitis results and it will continue, 
as long as the infecting focus remains active. 

The proportion of antrum diseases having a dental origin, 
which is now commonly given as twenty per cent, was rated by 
earlier rhinologists as high as eighty, or even ninety per cent. 
The great difference is attributed to the discovery of other 
etiological factors. It is true that causes not formerly recog- 
nized are now held responsible for a great deal of sinusitis, but 
I think there has also been a decrease in the number of odonto- 
pathy cases; a decrease, not only relative, but actual, and that 
this results from efficient prophylaxis, whose use is due to the 
cooperation of dentists with medical men. This cooperation 
has led to much greater intelligence regarding the relations ex- 
isting between the antrum and the teeth, together with their 
appendages, and, as a result, much greater attention is given 
to prevent the interorganic extension of disease. 1 

1 Laryngologists have rendered a great service in bridging the chasms, which 



124 NOSE, THROAT AND EAR 

The decision that the intractable sinusitis is, in part at least, 
of dental origin, indicates the extraction of some of the teeth 
whose roots invade the antrum. It is usually sufficient to 
remove the second bicuspid and the first molar, and their loss, 
under the circumstances, is not equivalent to the sacrifice of 
sound living teeth. In the cases here considered, these teeth 
are nearly always already devitalized and have been the subjects 
of reparative work. Their condition, when examined after ex- 
traction, often shows that they are already far on the road to 
loosening and spontaneous shedding. 

After removal of the teeth, the hole in the antrum floor 
which had contained their roots, must be enlarged under 
local anaesthesia by a rongeur or a drill like that shown in 
Fig. 55. This perforation must be of sufficient size to allow 
free drainage and thorough irrigation. The normal salt 
solution answers very well as an irrigating liquid and it should 
be used once each day until improvement is well advanced; or 
until it becomes evident that further operative work is nec- 
essary. This drainage has the advantage that, when the 
head is erect, gravity gives much assistance and not infre- 

formerly separated scientific workers, who sought the same ultimate object; 
but approached it by different routes. Aural surgeons have gained the coopera- 
tion of the teachers of deaf mutes; a body of capable and earnest educators for a 
long time wholly isolated from the medical profession and having little sympathy 
with it. At present, they meet in conferences with otologists, laboring together 
with them to rehabilitate the deaf and the mutual effort is accomplishing much 
for the benefit of this class of defectives. So too, the rhinologist has come close 
to the operating dentist, who in the future may occupy a place beside the gyne- 
cologic and the ophthalmic surgeon, as a practitioner of the healing art, equipped 
with a general medical education and adding special knowledge and skill concern- 
with a general medical education and adding special knowledge and skill con- 
cerning a particular group of organs; the ideal position of the genuine specialist. 
In the mean time, the rift grows wider between the dental surgeon and the 
mechanical dentist, whose post is not beside the patient; but in the work shop. 
The making of artificial teeth and vulcanite plates will come to be considered a 
handicraft, highly specialized and remunerative, but nevertheless a trade, side 
by side with grinding lenses and making supports and braces, occupations pro- 
ducing the mechanical aids required in the professional work of the ophthalmic 
and the orthopaedic surgeons. 



THE NASAL SINUSES 



125 



quently the antrum thus drained, recovers a condition of 
health. If this does not occur, the reason is found in the 
extensive and deep-seated inflammation which has taken hold 
of the mural structures; or in some constitutional dyscrasia, 
which impedes the cure. In either case where the patient 
is tending to convalescence, and also where the sinusitis is 
recalcitrant, no further surgical procedures should 
be undertaken from the lower boundary of the 
antrum. After the elimination of any continuing 
infection from the dental side, as has been done 
by the extraction of the teeth and the perfora- 
tion of the floor, all further measures can be 
better directed from above the alveolar border on 
the side of the sinus. The incision through the 
antrum floor will gradually close by natural re- 
pair, plastic work of any sort being very rarely 
needed. After its closure, the missing teeth may 
be substituted by artificial ones held in place 
either by a plate or by bridgework. 

In the cases where the walls have become so 
thoroughly diseased that all previously described 
measures have not been able to put an end to 
the morbid processes, the sinusitis must be 
treated by making an outlet large enough for 
thorough-going surgery. It should be remem- 
bered that the ground has been cleared for this 
operation by the ablation of the tissues in the 
nosogenic region; so that the intranasal structures 
have been, as far as possible, restored to a nor- 
mal condition and the procedure, now to be under- 
taken, concerns the antrum only. This operation 
(Cladwell-Luc) is here described, as performed for the cure of 
the sinus on the left side. The patient is prepared with the 
same care as for other important procedures and general an- 
aesthesia is induced by the inhalation of ether; the body oc- 
cupies the dorsal posture, on a table, and the head is turned 



Fig. 55 — 
Cohen's hand 
drill for perfo- 
rating the 
alveolar wall 
of the antrum. 



126 NOSE, THROAT AND EAR 

over upon the right side. The right nostril is lightly packed, 
to prevent blood escaping into the pharynx and trachea. 

The upper lip, on the left side, is lifted up toward the eye 
and held in that position by a retractor: this exposes the 
groove formed by the superior maxillary bone and its cover- 
ings joining the lip and cheek, the mucosa of the outer side 
of the jaw being here reflected over the inner surface of the 
lip. A short distance below this groove and parallel with 
it, an incision is made beginning at the median line and con- 
tinuing past the second premolar tooth, a distance of some- 
what more than an inch, and cutting down to the periosteum. 
The mucosa and submucosa on the dental side are apt to re- 
tract; allowance is made for this and the periosteum is di- 
vided in a line parallel with the former incision, but slightly 
nearer the teeth; it is then separated from the bone by an 
elevator and held out of the way with a retractor. The anterior 
wall of the sinus is now perforated by a chisel or trephine and 
the opening subsequently enlarged with biting forceps, or 
other suitable instrument, until it is large enough for the 
work required. It may be that visual examination will show 
an internal condition that necessitates only a small aperture 
for an inspection by reflected light and for the passage of 
probes, nozzles, curettes, etc. On the other hand, such a con- 
dition may be disclosed, as demands the introduction of 
the surgeon's index-finger. The amount of bone to be re- 
moved must depend upon the indications observed (Fig. 56). 
In either case the periosteum is protected as far as circum- 
stances permit; at some points it can be drawn aside to re- 
move subjacent segments of bone. The mucosa of the an- 
terior wall, if healthy, is spared as much as possible, being 
incised and then turned back as flaps attached to the margin 
of the aperture. By rays reflected from the head mirror, 
the interior of the antrum must now be thoroughly inspected 
and, if there are any spots of a suspicious kind, the ocular 
examination must be supplemented by using probes and 
even the index-finger. Thorough examination is to be fol- 



THE NASAL SINUSES 



127 



lowed by removal of all noxious substances, so as to give the 
reparative forces every possible opportunity to effect a cure. 
The cavity must be freed not only of all inflammatory prod- 
ucts, but of exostoses and other growths springing from the 
inner surface of the walls. Sometimes lamina of bone are 
so extensive as to form partial partitions, creating recesses 
within the sinus. All such obstructions must be broken down, 
making the antrum a single, vacant cavity. The mucosa and 




Fig. 56. — Caldwell-Luc operation upon the maxillary sinus. 



submucosa, when in a degenerated condition, must be re- 
moved with the curette. Care should be taken to avoid 
wounding the nasal duct and lachrymal canal, and equal 
caution observed regarding the infraorbital nerve, which 
passes along the antrum wall; sometimes protected by an 
osseous sheath, but occasionally lying in an open groove. To 
provide a route for adequate and permanent drainage of the 



128 NOSE, THROAT AND EAR 

sinus, its nasal wall, near the inferior turbinate, a locality 
within the field of operation upon the nosogenic area, is per- 
forated; a circular piece of bone half an inch in diameter being 
ablated together with its coverings upon the antral side. 
The mucosa of its nasal surface is dissected off in small flaps 
and these are pushed through the aperture where their raw 
surfaces become agglutinated and form a margin for the 
artificial orifice. In favorable cases, this opening supplies 
very satisfactory drainage and ventilation. After the two 
apertures mentioned have been made and all detritus re- 
moved, the preliminary nostril-packing is taken out and 
the antrum packed by a strip of iodoform gauze, one end of 
which projects from the left nostril. In a day or two, this 
gauze is removed and no subsequent treatment is commonly 
necessary, except daily irrigations with normal salt solu- 
tion for a short time. The wound of the gum rarely requires 
suturing. 

The frontal sinus, absent in infancy, is gradually developed 
by separation between the inner and outer tables of the frontal 
bone. The cavity so produced is over the roof of the orbit, 
which thus constitutes the sinus floor. The edge of the rift, 
where the two tables are again in contact, is about half way up 
the forehead and two-thirds of the distance from the median 
line to the outer end of the eyebrow, or superciliary ridge; 
this ridge is caused by the anterior convexity of the sinus, 
as is also a prominence just above the root of the nose, termed 
the nasal eminence. The sinus upon the right side is sepa- 
rated from that on the left by a thin osseous plate, or septum, 
which frequently is incomplete, so that the two chambers com- 
municate. A less common anomaly is an imperfectly de- 
veloped floor, leaving an opening into the orbit; there may 
also occur osseous extensions forming partial partitions, within 
the cavity, and sometimes one sinus is much larger than the 
other. 

The internal surface of the walls is covered by a mucous 
membrane, with ciliated epithelium, and this continues into 



THE NASAL SINUSES 120. 

the naso-frontal canal which extends downward to the infun- 
dibulum and has its orifice in the middle meatus of the nose. 
This is the normal route for the drainage and ventilation of the 
frontal sinus and it often serves as a passageway for pathogenic 
substances carrying infection from the nostrils. 

The symptoms of frontal sinusitis are a sense of fullness and • 
weight above the eyes and frontal headache; the pain is of a 
neuralgic kind and very often has a peculiar characteristic, 
which is distinctive. Upon getting up in the morning, the 
patient is attacked by neuralgia, either of the orbit or forehead; 
this continues for a variable time, usually an hour or two, and 
is frequently severe; it then ceases quite abruptly, but returns 
upon the following morning, reproducing the same phenomena. 
Whenever neuralgia of this sort comes under our observation, 
we should make search for disease of the frontal sinus, as it is 
an almost pathognomonic sign. Its occurrence is explained in 
this way. The naso-frontal duct is of small caliber and, when 
the body is recumbent, drainage through its aperture is slow 
and easily interrupted; much pus may accumulate during the 
hours of sleep and, in the morning, when the pressure of this 
liquid comes upon the orbital wall, the supraorbital and other 
branches of the frontal nerve are irritated, causing the neuralgia. 
As the patient moves about in the erect posture, the accumu- 
lated pus tends to escape through the duct, its discharge being 
promoted both by gravity, as the passageway is now perpen- 
dicular, and by the movements of the head. This outflow at 
once relieves the pressure and the pain stops. The intermission 
continues until, during the following night, the sinus is again 
filled and the symptoms are repeated in the same order. If 
the duct becomes occluded, these remissions do not occur and 
the pain is constant, though, as is common in neuralgias, there 
is variation in its severity. 

While drainage is maintained, pus is discharged at the base 

of_the infundibulum and is found upon the surface of the lower 

turbinal, having oozed into the middle meatus. If obstruction 

becomes complete, no pus appears in the nostril, but its pressure, 

9 



13° 



NOSE, THROAT AND EAR 



while incarcerated, may be indicated by bulging of the sinus 
wall above the eyebrow and downward into the orbit. 

Treatment of the frontal sinus, as of the maxillary, begins 
with correction of abnormal conditions in the nasal passages 
and, as its second stage, ablates the morbid tissues within the 
nosogenic area. Only in event of the failure of these measures, 

do we undertake the more rad- 
ical operations. Sometimes 
the presence of certain imminent 
dangers may compel an imme- 
diate opening of the sinus from 
the outside, but, barring such 
urgency, our next step is taken 
by the intranasal route, which is 
always preferable if its use will 
serve the purpose in view. 
Though the diagnosis is not likely 
to involve much difficulty, it is 
well to employ every aid avail- 
able and transillumination may 
be of assistance. An instrument 
devised for this purpose consists 
of two small incandescent lamps, 
each covered by a metal hood 
having a small aperture at its 
extremity (Fig. 57). These 
lamps are mounted on a bifur- 
cated handle with sufficient 
flexibility to allow of their adjust- 
ment, one under each eyebrow. They are also joined by wires, 
so as to form part of a circuit with a conveniently placed 
rheostat. In a darkened room, the unhooded spots are applied 
to the curves under the eyebrows and the circuit is closed, so 
that the effect upon the two chambers can be compared. If 
light be transmitted through one and not the other, it signifies 
the presence of pus in the dark sinus, or else such a thicken- 




Fig. 57. — Berkett's duplex trans- 
illuminator for illuminating both 
frontal sinuses at the same time. 



THE NASAL SINUSES 131 

ing of the walls as cuts off the rays. Skiagraphs may supply 
corroborating proof of the presence of dense pus or marked 
hypertrophy of the anterior wall, but a thin liquid will not 
obstruct the x-ray. Both of these tests are adjuvants and 
should not be given too much confidence, when they are un- 
supported by other evidence. 

The intranasal operation is performed under local anaesthesia 
and the self-retaining nasal speculum exposes the middle fossa, 
as in exenteration of the middle turbinal. If during that 
operation the bulla ethmoidalis and process uncinatus escaped 
removal, they must now be extirpated by the curette, chisel, 
or rongeur forceps, and free access obtained to the lower aper- 
ture of the naso-frontal duct. A slender probe is then passed 
up through this duct until the distance of its penetration 
shows that its point has entered the sinus; as the instrument 
may be gripped in the curved passage, the feeling of release 
communicated to the hand, when the probe reaches open space, 
may not be felt and the surgeon must watch how much of the 
instrument's length has disappeared within the duct. This 
catheterization of the duct may prove difficult; because in- 
flammation has made the wall thick and uneven, but its im- 
portance justifies patient effort and the trial of different imple- 
ments; the filiform bougie may prove useful here, as it does in 
passing through a nearly impervious urethra. When the 
withdrawn probe is followed by pus, its entrance to the sinus 
is proved beyond doubt. If even a thread like outflow is 
established, much has been accomplished; for such a discharge 
will relieve pressure and, in an hour or two, notably diminish 
the purulent accumulation, so that nothing further may be- 
advisable at the time. 

Upon the following day, with renewal of the local anaesthesia, 
the duct should be dilated with one of Freeman's graduated 
sinus probes, or other suitable instrument, and the facility for 
drainage thus improved. If in repeated sittings the duct can 
be so enlarged as to admit a small canula (or soft catheter 
with stillette) through which an irrigating fluid like normal 



I32 NOSE, THROAT AND EAR 

salt solution, can be injected; no further operation may be 
required and, with daily sounding, to keep the duct patulous, 
and daily irrigation, to keep the sinus clean; the case may 
steadily advance to a satisfactory cure. If sufficient enlarge- 
ment of the outlet cannot be secured by these means, the probe 
is used as a guide to introduce a curved rasp (Good's or Sulli- 
van's) backed by a protector of similar curve, to guard against 
intracranial perforation. The teeth of this rasp, shown in 
Fig. 58, are upon its concave surface and, acting with a saw- 
like motion, they make a groove toward the ridge of the nose 




Fig. 58.— Sullivan's frontal sinus rasps. 

and parallel with the nasal septum. The rasp cuts away one 
side of the naso-f rontal canal and the anterior part of the sinus 
floor, which is contiguous to its upper orifice. This gives ample 
room for irrigation, drainage and ventilation, with the sacrifice of 
only a small part of the mucous membrane of the sinus. Healing 
takes place by granulation and excessive hystogeny should be 
prevented by using an eight per cent, solution of silver nitrate, 
fused chronic acid, or the curette. Immediately after rasping, 
it may be necessary to pack the channel with a narrow 
strip of iodoform gauze, to control bleeding, and this dressing 
can usually be removed in a few hours. 

There are but three conditions, which call for a radical 
external operation upon the frontal sinus: (1) The failure 
of the intranasal procedures to overcome the disease; (2) 
a situation which precludes the performance of operations 



THE NASAL SINUSES 133 

of an intranasal kind; and (3) imminent peril of complications 
endangering life or vision. The second condition arises from 
the obstruction of the fossae by polypi or other neoplasms, 
whose presence hinders the intranasal measures described, 
and whose removal with the subsequent period of recovery 
would cause a delay longer than permissible, before combating 
the sinus disease. The third condition includes the symp- 
toms presaging the development of very grave complications: 
the invasion of the brain membranes and the onset of men- 
ingitis; the escape of pus into the orbit endangering fulminat- 
ing ophthalmitis and loss of sight ; a profuse and foetid discharge 
with indications of general septicaemia. 

A frontal operation (Ogston-Luc) which enters the cavity 
from the superciliary ridge was designed to remove all morbid 
tissue, without obliterating the sinus, or greatly diminish- 
ing its size. It is done under general anaesthesia. The 
eyebrow is shaved and the integument for some distance care- 
fully sterilized. An incision is made beginning at the median 
line, just above the naso-frontal suture, extending almost to 
the outer extremity of the eyebrow, and going down to the 
bone, care being taken not to injure the supraorbital nerve. 
The soft tissues are now separated from the outer table of 
the frontal bone, with an elevator, and held back by retractors. 
The proper spot for the perforation of the sinus wall is found by 
drawing a line parallel with the crest of the nose and perpen- 
dicular to this another line passing through the supraorbital 
foramina; a point one centimeter to the right of the inter- 
section of these lines is the best place to puncture the right sinus, 
and a point correspondingly situated on the left side is best 
for the other sinus. This perforation is made with Randall's 
hand gouge and enlarged with rongeur forceps to a size, which 
will permit thorough curettement of the cavity. The naso- 
frontal duct is then enlarged, by curetting its anterior wall, 
until its caliber is sufficient to insure ample drainage. All 
ethmoidal cells, unless already removed by the operation 'upon 
the nosogenic area, are broken up and their detritus extracted 



134 NOSE, THROAT AND EAR 

through the enlarged duct and the perforated wall; the field 
of operation is freed, as far as possible, from shreds and scraps 
of incised tissue and then the sinus is packed with a strip 
of iodoform gauze, one end of which is carried through the 
naso-frontal canal and left pendulous in the nasal fossa. The 
external wound is aseptically sutured and covered by a roller 
bandage lightly applied, as protection against dust, friction, 
etc.; the gauze packing is removed in four or five days and 
after that, normal salt solution is used for irrigation, first at 
daily and afterward at longer intervals, until the reparative 
process is complete. Our success in this operation is much 
promoted by extirpation of the ethmoidal cells previously ef- 
fected, because it is hard to remove them thoroughly by upward 
carriage from the infundibulum to the frontal floor; failure to 
do so is the most common defect in this procedure. This 
drawback, of course, is absent when the operation is second- 
ary, but is always a possible reason for partial failure when* 
the Ogston-Luc method is used primarily to meet emergencies. 
In favorably ending cases, good frontal drainage and ventila- 
tion are permanently established and the disfigurement is 
not great, there being but little retraction of the perforated 
table of bone and suture scars being partly hidden by renewed 
growth of hair upon the eyebrow. 

The Killian operation is much more extensive. Prepara- 
tions, as regards anaesthesia and sterilization, are the 
same as those described above. The first incision extends 
from the outer extremity of the eyebrow to the median line, 
horizontally, and then downward to the root of the nose. 
This cut goes down to, but not through, the periosteum. 
The soft tissues are turned upward with an elevator and held 
by retractors, exposing the periosteum over the whole of the 
frontal bone upon the affected side; the periosteum is incised 
in a horizontal line five millimeters above the supraorbital 
ridge and reaching from the median line to the outer end of 
the eyebrow, it is then raised from the bone by an elevator 
over the whole exposed area and held out of the way by re- 



THE NASAL SINUSES 



135 



tractors. The periosteum is next divided by another incision 
whose beginning is slightly below the supraorbital ridge, on 
the nasal side of the supraorbital foramen, and which extends 
downward and inward to the root of the nose. Here, too, 
the bone is laid bare by lifting up the skin and all subjacent 
tissues, including the periosteum, upon the lower and outer 
side of the incision. After careful separation with the ele- 




Fig. 59. — Killian operation on frontal sinus: first stage. 



vator, the inverted layer is drawn outward toward the tem- 
poral bone, partly moving the contents of the orbit in the 
same direction. The above technique is followed to avoid 
displacing the coverings of the supraorbital arch and superior 
oblique muscle (Fig. 59). 

The next step is the perforation of the uncovered frontal 
bone with a trephine or gouge, and ultimately the entire 
anterior wall of the sinus is removed by enlarging this open- 



136 



NOSE, THROAT AND EAR 



ing; the cavity is cleared of all bony lamina and the mucous 
membrane is scraped off; finally a part of the floor is also re- 
moved and the ethmoid cells (should any remain) are extir- 
pated (Fig. 60). Haemorrhage is controlled by gauze pack- 
ing and, afterward, the extensive raw surface is treated with 
a one per cent, solution of zinc chloride, and kept open until 
healthy granulations begin to appear. The periosteum and 




Fig. 60. — Killian operation on frontal sinus: second stage. 

skin are now replaced, with as much accuracy as possible, and 
interrupted sutures inserted. Much care and patience are 
required during the .postoperative treatment, not only by the 
local conditions, but to keep the organism in the state best 
adapted to promote recovery after extensive laceration. In 
time, the remains of the sinus are, to a great extent, filled 
by connective tissue and by adipose cells extending up from 
the fat deposits in the orbit. . Considerable disfigurement is 



THE NASAL SINUSES 137 

apt to result from this operation, due partly to the sutures 
and partly to the retraction of the skin, which has lost the 
support of the anterior wall of the sinus; this may show as a 
permanent, deep indentation. 

There has recently come into use a new method of operat- 
ing upon the frontal sinus for which we are indebted to re- 
searches made by Mosher, and which bears his name. This 
operation was suggested by deductive reasoning, or at least 
has its full support. Obviously the intranasal route to the 
frontal sinus is preferable to those requiring external lacera- 
tions, if the inner passage can attain our object. The intra- 
nasal technique contemplates such dilation of the frontonasal 
canal as shall restore its normal function as a sufficient outlet 
for the sinus. Just here is the difficulty. The process of 
dilation is slow and, when the eye or the brain is imperiled by 
fulminating disease of the sinus, we dare not wait and must 
ignore other considerations and make an entrance into the 
cavity with all dispatch, which has usually meant penetra- 
tion of the forehead. Even when this urgency is lacking, 
the method by dilation may disappoint us. The frontonasal 
canal may be so much damaged by chronic disease that it is 
beyond repair and, after patient dilation with bougies and 
even enlargement with the saw-tooth rasp, still fails to per- 
form its normal function and gives the sinus only precarious 
and intermittent drainage. It is not meant that such a 
disappointing result is common, but it may occur, to our 
mortification, in a small proportion of cases where the lumen 
of the duct is narrowed by incurable strictures. If another 
passageway, capable of giving free drainage and practicable 
access to the sinus, can be substituted in place of the out- 
worn frontonasal canal, the difficulty mentioned will be ob- 
viated and if, in addition, such substitution can be quickly ef- 
fected, external operations will be seldom required. 

Mosher observed in the wall of the nasal fossa, just above 
the point of attachment of the anterior part of the middle 
turbinate, a spot where the osseous partition between the fossa 



138 



NOSE, THROAT AND EAR 



and the frontonasal duct is extremely thin. He demon- 
strated that this delicate lamina of bone is easily broken 
through and its penetration is not productive of haemor- 
rhage or other objectionable effect. The opening thus made 
enters the duct very near its upper end, above the range of 
strictures and close to the superior orifice in the floor of the 
frontal sinus. The distance, by this route, from the sinus 




Fig. 



61. — Mosher's operation; the curette has broken through the thin osseous 
plate into the fronto-nasal canal. 



to the corresponding nasal fossa is about half an inch and 
the course is nearly a straight line. This route can be opened 
up in a single operation consuming but little time, and when 
open, it affords access to the sinus for both inspection and 
treatment and provides constant and adequate drainage. 

The operation, devised in pursuance of the conditions 
described, is performed under either local or general anaesthesia 
and with the usual precautions as to cleansing and steriliza- 
tion. The nostril is distended with a self-retaining speculum 
and a small, moderately sharp curette is introduced with its 



THE NASAL SINUSES 



139 



cutting edge turned toward the orbit until it reaches a point 
slightly above the vacancy left by ablation of the anterior 
part of the middle turbinal, previously removed (see Fig. 
43). Here is encountered the thin osseous partition referred 
to and this is broken through with the curette (Fig. 61). The 
opening is enlarged sufficiently to afford ready passage for the 
head of the instrument which is then advanced to the upper 
orifice of the frontonasal canal where enough space is exca- 




Fig. 62. — Final stage of Mosher's operation. 



vated to allow the curette to enter the sinus (Fig. 62). The 
instrument is then partially retracted and the anterior eth- 
moid cells ablated by rotating the curette head and giving 
it a to and fro motion. The curette is now advanced toward 
the sphenoidal sinus and removes the posterior ethmoid cells. 
The frontal sinus is explored with a blunt probe which, after 
being wound with cotton, is employed for the removal of any 
thing which should be extracted, and subsequently the clean- 
liness of the cavity is assured by irrigation which is effected 



140 NOSE, THROAT AND EAR 

by introducing a tube through the recently made mural open- 
ing and the natural orifice in the floor of the sinus. The only 
dressing usually required is a pledget of sterile gauze and 
the raw surfaces, left by the curette, heal in a short time by 
granulation. As free drainage takes place directly into the 
nasal fossa, the frontonasal canal is superseded by the new- 
passageway, and the cessation of its functional activity be- 
comes a matter of minor concern. It requires no further 
attention, except such as is necessary to prevent it from be- 
coming a nidus for germs, or playing some other nosogenic 
part. 

Theoretically, Mosher's operation fulfils the indications 
calling for opening of the frontal sinus in an admirable way 
and that too with but little surgical interference and a mini- 
mum of laceration. Its technique has the marked advantage 
of being simple and direct. The period that this procedure 
has been in use is too brief to justify conclusions as to second- 
ary and remote results, whose character can be known only 
after the lapse of a considerable time, but so far as judgment 
may be based upon experience already gained, I esteem the 
operation highly and consider it a valuable addition to our 
surgical therapeutics. 

The sphenoidal sinuses are situated near the center of the 
sphenoid bone, one on each side of the osseous lamella, which 
articulates with the perpendicular plate of the ethmoid bone, 
and thus constitutes the posterior segment of the nasal septum. 
In size and shape they exhibit so much diversity that they can 
hardly be said to have a normal type. During infancy they 
are absent, their development beginning in childhood and con- 
tinuing until the thirtieth or fortieth year, when they attain 
their full size which remains unchanged to the end of life. 
One of the sinuses is usually larger than the other and the 
two often communicate through openings due to imperfect 
development of the osseous partition. Like other sinuses, 
they are lined with mucous membrane and each has but a 
single outlet, the osteum sphenoidale, which communicates 



THE NASAL SINUSES 141 

with the superior meatus of the nose. As this opening is on 
the anterior side of the sphenoid, it cannot be seen by pos- 
terior rhinoscopy and it is also hidden from a front view by 
the middle turbinal. After this and the contiguous structures 
in the nosogenic area have been ablated, it is possible, though 
not easy, to examine the osteum from in front by rays of 
reflected light. The posterior ethmoidal cells are near by and 
may be seen at the same inspection, unless concealed by 
irregularities upon the surface of the sphenoid bone. 

Whatever drainage and ventilation the sphenoid sinus 
has, must be through this osteum and its occlusion gives rise 
to the usual dangers of obstruction with the addition of one 
which is peculiarly distressing, the peril of blindness. Each 
sphenoid sinus is traversed by the canal ensheathing the 
optic nerve of that side. This canal is fragile and sometimes 
incomplete so that the nerve is liable to injury from purulent 
accumulations within the cavity. Sometimes optic neuritis 
thus produced runs such a rapid course that irremediable 
blindness is produced within a week, though these fulminating 
cases are mercifully rare. 

The signs of sphenoidal sinusitis are (prior to obstruction) 
the discharge of pus into the upper nasal meatus and headache 
referred mostly to the cerebellar region. The pain is neuralgic, 
wandering, and more or less intermittent. In considering the 
question of ocular symptoms, it must be borne in mind that 
the optic nerve transmits visual sensations, not those of pain, 
hence its danger signal is not algetic but dysoptic. Progres- 
sive dimness of vision, especially if unilateral, even if at- 
tended by little pain, demands an immediate investigation of 
the sphenoid sinus : should it be found inflamed, the eye symp- 
tom is of the gravest import. There is no time to lose : when 
something so deplorable as blindness is threatened, all details 
not absolutely necessary must be omitted, for the sake of dis- 
patch. With the patient under general anaesthesia, the osteum 
is to be exposed to view and, if necessary, dilated by the intro- 
duction of Ostrom's sphenoidal forceps (Fig. 63). The instru- 



142 



NOSE, THROAT AND EAR 



merit is advanced into the cavity and when its point has entered 
the sinus, the jaws are opened to seize a segment of the anterior 
wall which is bitten out by a backward movement of the cutting 
edge, as the handles are compressed. By repeating this man- 
ceuver, the entire front wall is cut away, bit by bit. The bone 
is sometimes over a quarter of an inch in thickness,\but the 
instruments are strongly made and quite capable of doing the 
work. All accessible cells of the posterior ethmoid group 




Fig. 63. — Operation upon the sphenoid sinus. Ostrom's forceps in situ. 



must be removed with the curette, the sinus cleansed and dis- 
infected, bleeding being controlled by the usual gauze packing. 
Of course, every care is taken not to injure the optic nerve. 
Postoperative treatment is upon the same plan as that fol- 
lowed with the other sinuses. 

It is an encouraging fact that this operation, if performed 
at an early stage of the optic neuritis, nearly always leads to its 
arrest, and has undoubtedly saved the sight of many eyes. 
In view of this, early diagnosis is of paramount importance and 
it would be a wise precaution to examine the sphenoid sinus in 



THE NASAL SINUSES 143 

every" case of amblyopia whose causation is at all doubtful. 
Sinus disease may exist without producing any nasal symptom 
sufficiently prominent to attract the attention of the patient 
who seeks medical aid solely on account of his eye trouble. An 
oculist sent me a patient suffering from intractable optic 
neuritis. The clinical history contained nothing to suggest 
involvement of the sphenoidal sinus, except an attack of coryza 
sometime before, but examination disclosed a latent empyema. 
I operated upon the sinus and the posterior ethmoid cells. 
Vision then began to improve and, in a few months, was fully 
restored. 



CHAPTER X 
NASAL DISFIGUREMENTS 

The nose is so prominent among the features of the human 
face that abnormalities of color or shape, even when slight, 
attract attention and when marked are peculiarly unsightly. 
These" abnormalities may or may not be associated with serious 
disease, organic or functional, but as their common characteristic 
is their unsightliness, it is better to designate them as disfigure- 
ments than as deformities, for in the class of deformities there 
are many lesions, such as septal hypertrophies and various 
neoplasms which may make no change in the external appear- 
ance of the nose. Those afflicted with pronounced nasal 
disfigurements sometimes suffer serious injury to their health 
even when the lesion does not impair any rhinologic function. 
By constant brooding over their misfortune, they become 
obsessed with the idea that everyone considers them repulsive 
and wishes to shun their society, and they misinterpret the 
trivial incidents of daily intercourse in accordance with this 
obsession. They become neurotic, morbidly suspicious and 
approach a condition of mental unsoundness. Such patients 
deserve sympathy, not due to the vain egotists who go about 
seeking the removal of some slight blemish to their overprized 
beauty. A patient of the latter sort is apt to give the physician 
much trouble, for no matter how judicious his treatment has 
been, she will be dissatisfied; will criticise him among her ac- 
quaintances and will make trial of another doctor. After a 
time she is likely to fall into the hands of some charlatan who 
will mislead her with promises of impossible results, as long as 
her money holds out. 

Cutting operations, which have such importance in general 
surgery, play but a small part in the treatment of nasal dis- 

144 



NASAL DISFIGUREMENTS 145 

figurements and rhinologists have felt the need of an appella- 
tion which would be accurately descriptive and several text 
books use the words " cosmetic surgery." The term cosmetic 
is objectionable; it is alien to scientific nomenclature and is 
suggestive of soaps, perfumes, the manicure and the "beauty 
doctor." In public estimation, the cosmetic surgeon is akin to 
the chiropodist, and the name should be replaced by one which 
is both significant and dignified. Caleidic (kalos -\- eidos: 
comely + form) is a substitute for cosmetic which correctly 
expresses the idea and is analogous in derivation to other 
medical terms. 

Among the disfigurements due to abnormal coloration is that 
caused by long-continued abuse of alcohol. From the bridge 
downward the nose is red, the shade growing darker until upon 
the tip it is nearly purple. The tip is enlarged and bulbous, 
while there is much thickening of the alas nasi, also rugosity 
of the skin due to permanent distension of the cutaneous capil- 
laries. 1 Such noses were formerly a very common sight upon 
our streets, but for some reason are now seldom encountered. 
When of long continuance the condition is incurable, but at 
an early stage, when there is but slight degeneration of the 
blood vessels, much good can be done, provided the abuse of 
alcohol is stopped. Men, who have overcome their intemper- 
ate habit, are very anxious to be freed from this sign of their 
former weakness and are willing to follow instructions faithfully 
and patiently, a strong point in their favor. Good hygienic 
conditions are important and such constitutional remedies 
are indicated as will promote elimination and prevent haemic 
congestion and stasis. Topically, massage will help to conserve 
and restore the elasticity of the walls of the distended capil- 
laries. Moderate bilateral pressure applied for ten or fifteen 
minutes, three or four times during the twenty-four hours, is 

1 In the following lines of mocking satire, the German students have likened 
the red, swollen nose to a crimson banner, leading an army of drunkards: 

"Salve vexillum rubentium nasorum, 
Signum exercitus ebriosorum!" 



146 NOSE, THROAT AND EAR 

beneficial. It mechanically empties the engorged vessels, and 
though the blood returns after pressure is removed, yet if this 
treatment be persistently followed for several weeks, there will 
be observed a gradual diminution in size accompanied by slow 
fading of the dark red color. The officinal tincture of iodine 
should be applied over the area of discoloration semi-weekly. 
Used with long intervals, it does not harm the congested 
skin and it directly promotes the catabasis of the superfluous 
cells which should be removed from the subcutaneous tissues. 
It must be remembered that these measures are recommended 
only in cases where degenerative changes have not proceeded far. 
In the last stages of chronic alcoholism, when the nose is nearly 
necrotic, rubbing, pressure, or any other disturbance may be 
very harmful. 

Large scars upon the surface of the nose are very unsightly. 
They generally have a white, glistening surface and may be 
crossed by dark blue lines. Their origin is sometimes trau- 
matic, but most frequently furuncular, their cause being the 
vicious healing of abscesses which, instead of being lanced, 
have been "left to nature" and have opened by ulceration through 
a segment of devitalized skin. The fibrous tissue of such scars 
has often subjacent attachments to the cartilage, if they are 
situated upon the alas nasi, and to the periosteum if near the 
nasal bridge. These prevent the movement of the skin and the 
various contractions of the facial muscles, instead of producing 
change of expression, as they should, cause distortion of the 
countenance. 

Allyl sulpho-carbamide (thiosinamine) has the property of 
softening cicatricial tissue. It is not very soluble in water, 
but a five per cent, solution can be made by incorporating 
twelve grains with two fluidrams of glycerine and the same 
quantity of water. Four or five minims of this solution should 
be hypodermically injected at the margin of the scar, keeping 
the needle nearly parallel with the surface, to avoid wounding 
the perichondrium or periosteum. If the remedy is soon 
absorbed, the injection may be repeated each day, a different 



NASAL DISFIGUREMENTS 1 47 

margin of the scar being used for the successive punctures. If 
absorption proves slow, longer intervals must be allowed. 
Pain is commonly slight; in exceptional cases it may be severe 
and require the previous injection of a few drops of a four per 
cent, solution of cocaine. The scar tissue should be rendered 
soft and flexible by from six to twelve injections. As soon as 
there is notable alteration, massage should be used with the 
object of loosening the underlying attachments, restoring the 
motility of the skin and bringing back the normal color, by 
releasing the constricted capillaries. Absorption of redundant 
cellular tissue will be promoted by painting, at weekly or semi- 
weekly intervals, with the tincture of iodine. These measures, 
when skilfully and persistently employed, often accomplish 
much, and though a perfect cure cannot be anticipated, yet 
the disfigurement and the distortion of facial expression may 
both be so much lessened that what remains is inconspicuous; 
when that stage of improvement is reached, the purpose of the 
treatment is virtually attained. 

Eczema and other skin diseases cause discolorations of the 
nasal integument similar to those observed in other regions, 
and they call for the same dermatological treatment, with the 
proviso that appearance is in this locality of far greater con- 
sequence than in parts covered by clothing. 

Disfigurements due to abnormal shape may be congenital, 
traumatic, or the result of disease. Extensive destruction of 
the nasal skin and subdermal tissues is often brought about by 
syphilis, and here the malady works dreadful ravages. The 
gaping chasm, occupying the center of the face and extending 
backward nearly to the naso-pharynx, is repulsive in the last 
degree. When such devastation has been wrought, the only 
hope is in a plastic operation. To secure a sufficient supply of 
plastic material, without dangerous mutilation in other quarters, 
is a difficult factor among many embarrassing conditions in 
these reparative procedures. Each case presents so many 
features peculiar to itself that it is very hard to generalize, 
beyond the statement of two principles which are applicable 



I48 NOSE, THROAT AND EAR 

to all operations of this class. First, strict asepsis is necessary, 
because there is much danger of infection where the area of 
raw surfaces is large and second, the plastic graft, whenceso- 
ever it be taken, must have an attachment to the tissues of its 
natural situation, which will give it an adequate supply of 
blood while it is forming connections with the raw surfaces in 
its new locality. Failure to provide for this makes the death 
of the graft inevitable and imperils the success of the whole 
operation. 

Disfigurements which do not involve destruction of the 
integument offer a more hopeful field for treatment. They 
may be due to cretinism, or other congenital cause, or may be 
sequels of tertiary syphilis, which sometimes excavates large 
cavities in the intranasal region without penetrating to the 
surface. Being deprived of the natural means of support, the 
skin together with the subcutaneous tissue sinks down into the 
underlying cavity. In this way is produced the familiar 
saddle nose, in which the normal elevation of the bridge is 
replaced by a transverse furrow, sometimes shallow and some- 
times so deep as to be on a level with the zygoma. There are 
many persons disfigured by this, or similar malformations, in 
whom the original cause has ceased to act; the morbific agent 
has been overcome either by treatment or in some other way; 
the nasal functions are fairly well performed, and the patient 
considers himself free from disease, but is distressingly conscious 
of his facial deformity. This group of cases is preeminently 
the province of caleidic surgery. In recent years, much success 
has attended the method of raising and supporting the collapsed 
tissues by injecting a substance which can remain harmlessly 
in the network of subcutaneous connective tissue, little in- 
fluenced by gravity and little diminished by absorption. The 
utility of the method depends upon the fact that nearly all the 
desired qualities are properties of paraffin. This is an organic 
solid formed by the union of several different hydrocarbons, 
in different proportions, and while the ratio of carbon to hydro- 



NASAL DISFIGUREMENTS 



149 



gen is always the same, samples of paraffin differ in physical 
properties such as density, melting point, etc. 

As paraffin melts at a moderate temperature, it can be in- 
jected in liquid form; as it is solid in the normal heat of the 
body, it can serve as a support; its specific gravity, though vary- 
ing in different samples, is always less 
than that of water and very close to that 
of adipose tissue, hence there is no sink- 
ing by weight like that occurring with 
leaden shot and other heavy projectiles; its 
translucent white color prevents any pig- 
mentation effects; as it is composed of 
saturated hydrocarbon, it is devoid of 
chemical affinities, is neither poisonous nor 
nutritious, and therefore may remain 
among the living tissues doing no harm 
and undergoing every little change. The 
instrument used for its injection is virtu- 
ally a large hypodermic syringe having 
the following features: The barrel con- 
sists of metal, not glass, and has the capac- 
ity of one fiuidram. It is strongly made 
and is armed with a strong, sharp needle 
of large caliber; the piston is operated by 
a screw, insuring slow injection of the 
liquid, drop by drop. 

The area of operation having been ren- 
dered insensitive by cocaine, the syringe 
is filled with the paraffin, previously lique- 
fied by heat, and the needle is inserted 
into the subdermal connective tissue un- 
derlying the depression (Fig. 64). If the amount of paraffin 
needed to restore the natural contour be small, it may all 
be injected at one sitting; otherwise, repeated operations 
may be required, and it is better to use too little than too 
much, for if the filling out is not complete, it is easy to inject 




Cm 



Fig. 64. — The injec- 
tion of paraffin for nasal 
disfigurement. 



150 NOSE, THROAT AND EAR 

more of the hydrocarbon and the portion added will coalesce 
with what is already in place, but if too much be injected, it 
is practically impossible to effect any withdrawal. Bleeding 
occurring at the puncture may be controlled by pressure with 
sterile gauze and the opening may then be sealed with collodion. 
As the paraffin solidifies, the stiffening mass should be modeled 
into a shape approximating as nearly as possible the natural 
form of the nose. 

Among untoward sequels of this operation there are on record 
some cases of embolism and thrombosis. They seem to have 
been produced by the needle's entering a blood vessel, a rare 
accident when the syringe is in skilful hands. In two pub- 
lished cases the embolus was dissolved by injections of ether and 
did no harm. There are also reports of infection in a few in- 
stances. The only safeguard against such a misfortune is pains- 
taking attention to all details of asepsis, both in preparation 
and in operating. When the injection is high up, as in saddle 
nose, there is risk of the paraffin spreading through the loose 
subdermal tissues near the inner canthus of the eye. This can 
be prevented by having an assistant, or the patient, make 
digital pressure on both sides of the nose just below the level of 
the eyebrow. 

It is said that some persons, whose nasal disfigurement had 
been treated by the injection method, found upon entering the 
boiler room of a ship, or some other superheated apartment, 
that the paraffin begin to liquefy, causing partial collapse of the 
nose; on the other hand, there are complaints that premature 
solidification of the injected material has prevented satisfactory 
modeling of the restored organ. Such accidents arise from 
using paraffin whose melting point is either too low or too high. 
This substance exhibits great variation in regard to the effect 
of heat, the different grades having melting points ranging all 
the way from 120 F. to 200 F. Between these limits are 
temperatures which would preclude the occurrence of both 
the mischances referred to, and as the tubes in which paraffin 
is supplied for surgical purposes commonly bear record of the 



NASAL DISFIGUREMENTS 151 

melting point upon their label, the rhinologist can provide 
himself with such a quality as will accurately meet the require- 
ments of his caleidic work. 

Operations, in the main successful, are sometimes followed 
by a partial disappointment, which is due not to any lack of 
surgical knowledge or skill, but to a want of artistic perception. 
A saddle nose built up with paraffin may appear of correct out- 
line and, while the features are in repose, no defect is exhibited; 
but when the facial muscles are thrown into strong action by 
laughter, or by any emotion of an intense kind, the countenance 
shows a certain distortion. Something is wrong with the nose; 
an observer may not be able to tell exactly what the fault is, 
but he is sure that the face looks unnatural, and from that 
perception it is but a step to recognize that the most prominent 
feature is in part a fabrication. The restored organ thus be- 
trays its secret, because its conformation is not in harmony 
with the other features; it is a well-shaped nose, but it lacks the 
particular shape proper to that individual face. The minute 
differences, upon which facial distinctions depend, may not be 
observed when the features are at rest, but they become im- 
pressive during emotional disturbance. 

It is said that a rhinologist averted a painful disappointment 
of this sort by an ingenious expedient, which though of limited 
applicability is extremely suggestive. His patient, whom he 
had cured of some intranasal troubles, was a man of great in- 
fluence in the business world, but took no part in social pleasures 
because he was morbidly sensitive regarding his saddle nose. 
The use of paraffin was strongly advised, but he hesitated, for 
he had heard of incongruous results like those just referred 
to and he feared to become an object of ridicule. The doctor, 
whose advice was at last accepted, employed a sculptor who 
made a thorough study of the patient's features, at rest and in 
all attitudes of motion, and then made a model in clay reproduc- 
ing the face, except that the disfigured nose was replaced by one 
such as the man should have had, a nose perfectly congruous with 
all the other features. The operation was then performed and 



152 NOSE, THROAT AND EAR 

the injected paraffin was moulded to the closest imitation of the 
nose modeled in clay. The rhinologist's ingenuity and patience 
led to the happiest results. The patient subsequently made 
many postprandial addresses and, although his countenance 
passed through the many changes incident to public speaking, 
auditors who had not previously known him enjoyed his oratory, 
quite unwitting that he had once been greatly disfigured and 
that his present nose was in large measure a work of plastic art. 



CHAPTER XI 
NASAL RELATIONS TO SPECIAL SENSES 

Nasal conditions, functional and structural, have im- 
portant bearings upon three of the special senses: smell, 
hearing and sight. The close anatomical relations between 
the breath-road and the organs of olfaction and of audition 
has been noted in Chap. I, but the connection of this road 
with the complex mechanism of the eye is less obvious and 
was for a long time overlooked. In recent years much atten- 
tion has been given to the matter with very good results. 

The olfactory nerve, which is the exclusive organ of the sense 
of smell, distributes its terminals over the upper third of 
the nasal septum and also over the superior and middle tur- 
binate, the area occupied by these filaments showing some 
variation in different individuals without any corresponding 
variations in acuteness of smell which, in fact, depends more 
on other things than upon the number of afferent nervuli, 
so long as there is a fair supply in normal condition. What 
is the minimum amount of olfactory nerve substance com- 
patible with preservation of the sense has not been determined. 

Many of the lower animals have more acute smell than 
man, some of these having also a relatively greater area de- 
voted to the ramification of olfactory nerves. These facts 
have inspired a great deal of fanciful writing, fine-spun theories 
regarding transmission of traits, vestiges, survivals, rudi- 
mentary organs and ativism. For all this there is little 
scientific foundation. The quick-scented animals cannot 
be formed into a group to hold a place in any ascending or 
descending biologic scale, whether the scale depends upon 
structural characteristics or upon degrees of intelligence. 
Even within the same genus the differences are very wide. 
iS3 



154 NOSE, THROAT AND EAR 

The olfactory power of the bloodhound is extraordinary and 
is the dog's sole reliance in pursuing its prey; this power is 
slight in the grayhound, which chases by sight, not scent, 
a fact indicated by its original name, "gaze hound." A 
South African Bushman can smell a lion at the distance of a 
mile, provided there is a breeze and the beast is to the wind- 
ward of the hunter. A white man would not recognize the 
leonine odor. This fact is often set forth as a proof that civi- 
lized man is, by evolution, losing the sense of smell; but tea- 
testing experts, whose discrimination depends chiefly upon 
olfaction in distinguishing a score of flavors, exhibit a keen- 
ness of smell more astonishing than that of the Bushman, 
and in their case heredity very seldom plays any part at 
all. 

These phenomena have elicited another explanation: that 
differences in olfaction in animals, but especially in man, 
depend upon education. This suggestion has encountered 
objection, even ridicule, because there is no way by which 
the nerves may be multiplied nor their functionating power 
agumented; what can training do? 

The objectors do not comprehend the proposition. It is 
true the nerve impulses cannot be modified by training. The 
sensations are not modified. The man who has learned to 
test teas has the same sensations today, when he can dis- 
criminate among a score of flavors, as he had when as a tyro 
he could not distinguish more than three or four. ^The re- 
sult of education is wholly psychic: the change is not in his 
sensations, but in the use he makes of the sensations. Since 
this matter applies to all the special senses, which we shall 
consider, it is advantageously explained here. 

External objects impress upon the nerve terminals sensa- 
tions; the nerves transmit these to the brain and from them 
the brain forms its concept, or idea, of the external object. 
If the object is novel, many sensations may be necessary to 
form a complete concept; but if it be familiar, a few sensa- 
tions furnish a part of the concept and the rest is supplied 



NASAL RELATIONS TO SPECIAL SENSES 155 

by the recollection the brain retains of former concepts, which 
are suggested by the few sensations now experienced. A 
good illustration is furnished by the diverse effects of two 
languages. Let some one read to you an English passage 
containing a thousand words and occupy ten minutes in the 
reading. You find the rate of utterance deliberate and 
get a clear idea of every word. Let this be followed by read- 
ing in ten minutes this same passage translated into a lan- 
guage with which you are only partially acquainted. It 
will seem to you that the reader is proceeding at a rapid rate, 
that he is slurring many words and dropping out many syl- 
lables; you cannot grasp the signification and ask him to 
go slower, yet the clock proves that his utterance in both in- 
stances was at the same rate. 

The fact is that the reader has omitted a great many sounds 
in both cases; only a part of the words have been phonated. 
You cannot understand the foreign language without the 
missing words, but you are so familiar with the mother tongue 
that your mind supplies what is lacking, because that is in- 
dicated by what is actually heard — a complete concept is 
made up from a few sensations, memory and association filling 
in the omissions. The process is so rapid and so sure that 
you are unconscious that many sounds have been suppressed. 

In this respect, the action of the other special senses is just 
like this action of the hearing. They give us a few sensations, 
the brain fills out what is lacking and we have a complete 
idea of the external object, provided that external object is 
familiar. Suppose the South African Bushman instanced 
above is accompanied by a recently arrived European hunter. 
The breeze carries to them a peculiar odor, faint and momen- 
tary, which imparts to each the same olfactory sensation. 
To the white man it is a new thing and devoid of meaning. 
It is so slight that it barely produces a momentary impression 
scarcely exciting his notice; if he does notice it, he thinks it 
one more among the novel vegetable and animal smells borne 
by the wind across the veldt. To the Bushman it is intensely 



!ij6 NOSE, THROAT AND EAR 

significant; he halts, with every faculty alert, waiting for a 
repetition of the sensation; in a minute or two it comes, a 
mere whiff, but its quality is the same; motionless and silent, 
he awaits another repetition; the wind brings the third sensa- 
tion and the hunter is sure. It is the odor which has been a 
subject of his thought since boyhood; on recognizing it his 
success as a lion stalker, even the safety of his life, has de- 
pended for years. It is one of his important items of knowl- 
edge, and those three evanescent sensations give rise to a vivid 
concept of the king of beasts and suggest a whole train of 
memories. He tells his companion, with absolute confidence, 
that he scents a lion lurking in the area of bushes visible a mile 
to the windward. When the beast has been found and slain, 
the European's incredulity changes to astonished admiration 
and upon his return home, he may publish an elaborate hy- 
pothesis, explaining how the Bushman came to possess ex- 
traordinary olfactory powers with a wide area of nerve dis- 
tribution, the survival of a remote geologic age, and the baseless 
fancy may be considered scientific. 

Although the sense of smell ranks far below sight and hearing, 
it is an important function and its conservation means much to 
the organism. The early pharmacists depended largely upon 
it in determining the quality of crude drugs and, although 
pharmaceutical assaying now yields more accurate results, 
olfaction is by no means useless in the laboratory. The garlic- 
like smell of hydrogen arsenide has given warning that this 
gas was poisoning the air, and the peachy odor of the deadly 
hydrocyanic acid has told of its presence in the very nick of 
time. Before the introduction of instruments of precision, 
diagnosis was much assisted by the sense of smell, as is attested 
by medical text books published before the middle of the last 
century. The present-day city physician, who by some means 
is temporarily deprived of his accustomed aids, is at a great 
disadvantage in comparison with the "back-woods doctor," 
who relies wholly upon his own natural powers. 

Though in some ways substitutes may take the place of 



NASAL RELATIONS TO SPECIAL SENSES 1 57 

olfaction, they can in no respect perform its function as a 
pleasure-giving sense. Anosmia abolishes a group of physical 
gratifications which science is powerless to restore. The 
pleasures of eating and drinking, aside from the mere allaying 
of hunger and thirst, depend mainly upon olfaction. The 
gustatory nerves can recognize the sweet, the sour, the bitter, 
the pungent and the saline, but very little more. The multi- 
form modifications of these primary tastes depend upon 
flavors recognized by the olfactory nerves. The rich savor 
of roasted meat and the delicate bouquet of wines are made 
known by minute particles borne upon the air and impinging 
upon the nerve terminals distributed over the septum and 
turbinals. If both the anterior and posterior nares are 
occluded, the best grilled venison is hardly distinguishable from 
corned beef and the finest dry champagne differs little from 
water charged with carbonic acid. It has been proved that 
when mastication and insalivation are accompanied by pleasur- 
able sensations, the stomachic digestion is better than when 
pabulum is simply put into the mouth, like coal shoveled into 
a furnace, without any consciousness as to its quality. This is 
true whether the unconsciousness is due to such preoccupation 
of mind as prevents the eater from knowing what he is eating, 
or owing to abolition of the sense of smell, rendering normal 
gratification impossible. It is very probable that in this way 
anosmia becomes an influential, though unnoted, factor in the 
injury of digestion and the impairment of nutrition. 

Though in rhinological practice the nasal septum and turbi- 
nals are subjected to many operations, serious injury to olfac- 
tion is a rare consequence. Responsibility for damage to the 
function, or its abolition, rests nearly always upon syphilis, or 
upon atrophic rhinitis, either of these diseases being liable to 
destroy the nerve terminals distributed through the mucosa. 
It is therefore very important to safeguard this membrane, 
and if this can be done the function will incur but little danger 
for the nerve trunks usually resist the morbid process. Even 
if a large number of the terminals have been sacrificed, it is 



158 NOSE, THROAT AND EAR 

highly important to save the balance for the sense will be re- 
tained if the olfactory filaments upon one side of the nose or 
even a portion of them are preserved and, in view of the way 
in which the special senses act and of the psychic training which 
can make much of even a few sensations, it is a great boon to a 
patient to be saved even a modicum of the neural apparatus. 

The interdependence of diseases of the nose and those of the 
eye is a pathological truth, whose importance was not fully 
appreciated until a recent date, but when once brought before 
the profession it was accepted without controversy. That it 
met with so little dissent was due to the fact, promptly recog- 
nized, that such interdependence was rendered inherently 
probable by the anatomical relations of the two organs. The 
nasal cavities are separated from the orbit by a very thin wall 
of bone, which is pervious to heat, electricity and to the re- 
cently discovered forms of radiation (also partially to light, 
as proved by the phenomena of transillumination). Moreover 
the blood vessels, lymphatics and nerves of the two regions are 
intimately associated, for they are in close proximity and the 
branches supplying the two organs often come from a common 
trunk. In addition, the nasal duct passing through the lachry- 
mal canal furnishes a connecting pathway lined by a mucous 
membrane continuous with that of the nares and of the orbit, 
an open road between them, one that is often traversed by 
invading microbes. It is obvious that morbid conditions 
affecting one region may readily extend to the other and that 
this extension may occur in either direction. It seems, however, 
that transmission of disease from the nose to the eye is much 
more common than its converse. 

The nasal causation of ophthalmic lesions is (1) mechanical, 
(2) infectious, or (3) reflex. To determine the etiological re- 
lation is rationally the first step and, in all eye diseases, which 
may possibly have a nasal origin, the fossae and sinuses should 
be examined and any morbid conditions there found should be 
subjected to proper treatment. Such a course is justified by 
the record of numerous cases, in which removal of the nasal 



NASAL RELATIONS TO SPECIAL SENSES 1 59 

lesion has resulted in complete cure of the ophthalmic disease, 
which previously had seemed intractable. A further reason for 
such examination is the fact that the patient, while suffering 
much from the ocular malady, may be quite unconscious that 
there is anything wrong in the nose; the underlying morbid 
state may have existed for a long time, causing few symptoms 
and hence have been entirely overlooked. 

The occlusion of the nasal duct with the consequent overflow 
of tears and maceration of the lower eyelid and the subjoined 
skin of the cheek is frequently due to obstruction at its lower 
orifice where it empties into the inferior nasal meatus. If 
the stenosis has persisted for any length of time, strictures in 
different parts of the duct complicate the difficulty and very 
often there is suppuration. An accepted operation is that which 
elevates and rolls back the mucous membrane lining the nasal 
wall, removes the bone from the anterior side of the lachrymal 
canal, slits up the duct to the sac, cleanses it of all morbid 
products, and then replaces the mucous membrane, creating a 
new duct of larger lumen. Another operation is that devised 
by Yankauer and previously described. Intranasal hyper- 
trophies may cause oedema of the eyelids by pressure upon the 
blood vessels and the obvious treatment is the surgical reduction 
of the hypertrophy. 

Infections of the nasal passages and especially of the accessary 
sinuses may traverse the mucosa lining the lachrymal canal and 
attack the orbital tissues, causing suppuration and sometimes 
even abscess of the orbit. In such cases the detergent and anti- 
septic treatment must be applied in both regions. Conjunc- 
tivitis is often due to the extension of a preexisting rhinitis. 
When so produced, it improves under treatment but shows a 
marked tendency to relapses so long as the nasal inflammation 
continues. If this is cured, the eye generally makes a good 
and permanent recovery. 

Among reflex disturbances are contractions of the extra- 
ocular muscles, causing squinting; diplopia and various forms 
of asthenopia. There are also instances where grave ophthalmic 



l6o NOSE, THROAT AND EAR 

maladies, such as glaucoma, have a rhinologic origin. Just how 
they are produced is not known, but their nasal etiology is 
proved by the fact that when the nose is restored to a normal 
condition, the eye disease makes no further advance and 
sometimes complete recovery takes place. 

The judicious course in all these morbid states is to search 
carefully for any nasal abnormalities and endeavor to correct 
such as may exist. It will often be found that the restoration 
of health to one organ leads to recovery in the other, and even 
if this favorable result is not reached the patient is better off, 
as far as his nose is concerned, while the optic condition is no 
worse than before. 



CHAPTER XII 
EPISTAXIS 

Epistaxis is a symptom rather than a disease. The word by 
derivation and original usage signified the slow escape of blood 
from the nostrils, drop by drop, but as employed at present it 
includes all forms of bleeding from the intranasal tissues, 
whether very slight or dangerously profuse. 

Its predisposing causes are constitutional and local. Among 
the most important of the first class are haemophilia, scurvy, 
purpura, and some of the infectious fevers, notably typhoid; 
in addition stands anything which raises the blood pressure, 
either positively or relatively. Nephritis and arteriosclerosis 
directly increase the tension upon the vessel walls and hence the 
liability to extravasation, while the same result follows a de- 
crease in the counterbalancing pressure exterior to the body, 
which makes the tension relatively, though not positively, 
greater. Those crossing very high mountains, such as the 
Andes, where the air is rarefied, and those ascending to great 
altitudes in balloons have attacks of epistaxis, which in such 
instances is a natural prophylactic preventing apoplexy and 
visceral engorgement. Upon return to usual atmospheric 
conditions the attacks cease. The bleeding, which is called 
vicarious menstruation, may also be protective in its effects; 
it is doubtful whether the process is really vicarious, as this and 
similar phenomena may be the result of a general plan of com- 
pensation affecting all the organic functions and regulated by the 
ductless glands. When constitutional predisposition is strong, 
a very slight excitant is sufficient to cause haemorrhage; there 
is probably always an exciting cause, but it may seem so trivial 
as to be overlooked. This often occurs with the symptomatic 
epistaxis ushering in the first stage of typhoid fever, j 
n 161 



1 62 NOSE, THROAT AND EAR 

Predisposing causes of a local nature are nasal neoplasms, 
especially those of malignant character, like sarcoma, which 
bleeds very readily, and some of the intranasal hypertrophies 
accompanied by congestion. Rhinitis is not, per se, prone to 
produce epistaxis. 

The exciting causes are local and chief among them stands 
traumatism of many kinds, as we would naturally expect from 
the fact that the nose is so placed as to encounter many injuries. 
First, in point of frequency if not gravity, are hurts inflicted 
by the human fist, as in the prize ring and the fights among boys. 
The association of epistaxis with such blows is immemorial and 
hurts received in this way are commonly regarded Ugh tly; but 
the immediate results are sometimes serious and, in a large per- 
centage of cases, the intranasal diseases of adult life are etio- 
logically connected with these incidents of adolescence. The 
impact of such blows upon the outside of the nose may cause 
only a slight contusion, but the transmitted force ruptures 
intranasal blood vessels, usually those of the septum. Another 
exciting cause is picking at the mucosa with the finger nails, 
hairpins, glove buttoners and other seemingly harmless, but 
really injurious implements; so also is violent blowing of the 
nose. Rhinological operations necessarily cause some bleed- 
ing but can scarcely be classed among morbific causes as they 
are therapeutic measures. Precautions and correctives asso- 
ciated with surgical procedures are considered together with 
the operations. Foreign bodies in the nose, commonly small 
articles like buttons and cherry-stones inserted by eccentric 
children, who afterward conceal the act, are both predisposing 
and exciting causes, and when the origin of a haemorrhage is 
obscure, search should be made for them. 

The diagnosis of epistaxis is so obvious that spontaneous 
haemorrhage from another organ could scarcely be attributed to 
the nose but the converse is not so certain. If much blood has 
passed downward from the posterior nares, it may be expelled 
by coughing or vomiting giving rise to the impression that there 
is a lesion of the lungs or of the stomach. The differentiation 



EPISTAXIS 163 

really belongs to the diagnosis of haemoptysis and haematemesis; 
but it may be noted here that, if, when the patient is sitting up 
with the head inclined forward, blood exudes from the nasal 
vestibule, its source cannot be gastric or pulmonary; it must 
come from some place above the plane of the pharynx. A very 
important point as to the origin of the blood is the question 
whether it comes in part from the supernasal region, indicat- 
ing a fracture at the base of the skull. In traumatic cases, when 
haemostasis has taken place upon the surface of the septum and 
contiguous parts, and nevertheless blood continues to descend 
the nostrils, the existence of a fracture in the sphenoidal region 
becomes a matter for grave consideration. 

The treatment of epistaxis is practically restricted to cases of 
severity; slight bleeding, which in a short time stops spon- 
taneously, is seldom brought to the attention of the rhinologist. 
From this fact there are two logical deductions. The urgent 
feature in epistaxis as we see it is not the abnormality of some 
vessel or some morbid process, but the depletion of the body's 
supply of blood and how much yet remains above the minimum 
limit; moreover the supreme object of treatment is to stop the 
loss of blood. This being our paramount duty, we can ignore 
all the remedies recommended for their constitutional effect. 
Many such are mentioned in books and they have utility in 
treating the systemic conditions which act as predisposing 
causes ; but I know of none that have any value in checking the 
bleeding. They are useless in the emergency of the moment and 
that is what we must meet. When the patient is out of danger 
there will be time to consider constitutional dyscrasias and their 
proper treatment. 

As the therapeusis is wholly local, it is most important to 
find the bleeding spot. This may be anywhere in the intra- 
nasal region, but nine times out of ten it is upon the surface 
of the cartilaginous part of the septum, which is rendered 
extremely vascular by a close network of submucous vessels. 
To discover the site of the outflow the nostrils must be cleansed; 
the clots and all other contents should be washed out with water 



164 NOSE, THROAT AND EAR 

at a temperature of uo° F. This advice is contrary to the 
teaching of many, who say that clots should not be disturbed, 
as they are a starting point for a coagulation, which will 
eventually stop the haemorrhage. Instead of this, the bleed- 
ing goes on behind the clots, valuable time is lost and the 
patient imperiled. As soon as the obstructions are out of the 
way, cotton pledgets steeped in a solution of cocaine hydro- 
chlorate, eight per cent, and solution of epinephrin chloride, 
one-tenth of one per cent, should be inserted on the affected 
side and kept in place, till, their anaesthetic and ishaemic effect 
is fully produced. They temporarily lessen the haemorrhage 
and give a chance to use the nasal speculum, which should 
be at once introduced and the bleeding point located, if pos- 
sible. Here much depends upon the promptness and skill of 
the surgeon for the ischaemia is of short duration. If the 
rupture is found upon the cartilaginous septum, accessibility 
renders the subsequent procedures much easier. Haemostasis 
can be produced by a solution of silver nitrate (5j:fl- 5j) by 
chromic acid, by trichloracetic acid, or by the electrocautery, 
the choice of a styptic depending on the location of the spot 
and also upon the facilities available in circumstances re- 
quiring speedy action. 

If the bleeding point cannot be found or if there is diffused 
oozing over a large surface treatment with gelatin may be em- 
ployed. This substance liquefied by heat and sterilized is 
injected in sufficient quantity to fill the nasal cavities; upon 
cooling it solidifies and forms a sort of tampon which fits into 
all recesses and sinuosities. 

Packing with fibrous material, such as sterile gauze, is an 
old expedient, which holds its place among remedies of last 
resort, though it is open to serious objection, because it wholly 
stops drainage, leaving any septic discharges or any decom- 
posing liquids incarcerated in close proximity to the ear and 
the brain, whose infection may lead to otitis, or meningitis. 
Still the condition of imminent danger, in which packing 
is resorted to, fully justifies its use and, if the tampons are 



EPISTAXIS 165 

not allowed to remain more than twenty-four hours, they 
seldom do serious harm. Procrastination in their removal 
has caused most of the bad results. The danger is much 
greater if both the anterior and posterior orifices are plugged 
than if the latter remains open. 

Anterior packing is effected with a long strip of sterile gauze, 
one end of which is carried to the upper boundary of the 
intranasal space upon a blunt probe and the rest is added 
in short folds until the cavity is filled. The balance of the strip 
is then cut off after leaving an inch or so protruding from 
the vestibule; this can be attached to the outer surface of one 
of the alae nasi by a scrap of adhesive plaster. In twenty- 
four hours, or as much sooner as conditions permit, the gauze 
is removed by gentle traction upon the projecting end, its 
gradual withdrawal, in this way, causing no disturbance of 
the coagulation, which has taken place. When posterior 
plugging is demanded, the intranasal cavity must be cleansed 
and a soft catheter passed through the lower meatus from 
the vestibule to the naso-pharynx. This catheter has been 
threaded with a piece of stout silk ligature, eighteen inches 
long and doubled at the middle , so that the loop comes through 
the eyelet and is fastened by turning over the point. When 
the end of the catheter appears in the pharynx it is seized 
with forceps and drawn into the mouth, the loop is disen- 
gaged and traction made upon one strand of the silk till its free 
end appears, when this end is brought outside of the lips. 
The catheter is then gently drawn outward until freed from 
the other silk strand. At this stage of the procedure we 
have a cord entering the vestibule, extending to the naso- 
pharynx, there turning in an anterior direction and coming 
out through the mouth, there being a surplus in length at both 
ends. Gauze is now folded into a sheaf-like tampon, large 
enough to close the posterior outlet, and the middle segment 
of the cord is firmly bound around this tampon and securely 
knotted. The surgeon now, with his left hand, makes trac- 
tion upon the nasal end of the cord, gradually drawing the 



66 



NOSE THROAT AND EAR 



tampon backward into the pharynx and then upward to its 
place at the postnasal orifice, while with the forefinger of 
his right hand, he guides the sheaf past the soft palate and 
into the exact position it should occupy. Cotton or gauze 
is then introduced through the vestibule, to fill up the intra- 
nasal space, and finally the two ends of the silk cord are tied 
together, making the whole secure. 

This method of posterior packing is largely used and 
is recommended by the facility with which the tampon can 




Fig. 65. — Epistaxis; tampons applied to the anterior and posterior nares. 

be withdrawn from the naso-pharynx, even by one having 
little practical familiarity with the anatomy of the region; for 
the saturated plug of gauze can always be dislodged by a down- 
ward pull upon the cord, emerging from the fauces, and then 
readily drawn out through the mouth. On the other hand, 
there is a serious objection in the fact that, in some patients, 
the cord traversing the oral cavity causes nervous irrita- 
tion, provoking cough, sneezing, nausea and other symptoms 
quite harmful under the circumstances which require rest 



EPISTAXIS 167 

and quiet. On this account, a modification has been devised 
which dispenses with the cord passing through the mouth 
(Fig. 65). The technique of this procedure is just the same up 
to the point when the end of the catheter is seized and drawn 
outward. At this stage, instead of pulling one strand entirely 
into the mouth, the loop is drawn outward, free of the lips, 
and fastened around the middle of the gauze tampon, which 
is guided into place by the right forefinger as before described. 
After the tampon is attached to the doubled cord, the catheter 
is withdrawn and the left hand makes the traction along 
the nasal floor, as in the other method, except that this trac- 
tion employs the two cords, instead of only one. After the 
posterior tampon is properly placed and the anterior packing 
has been done, the two cords are tied at the vestibule and 
then wrapped around a small sheaf of gauze and knotted. 
This retainer, resting against the margins of the nostril, keeps 
the cords extended along the nasal floor without undue strain. 
To reopen the posterior orifice, the surgeon cuts the cords 
at the vestibule allowing them to slip backward and dislodges 
the tampon with his finger, or naso-pharyngeal forceps. This 
requires more skill than the simple traction of the other method 
but presents little difficulty to an operator of experience and 
dexterity. 



CHAPTER XIII 
THE NASO -PHARYNX 

When the breath-road emerges from the nares, it joins the 
food-road, passing backward from the lips, and for a distance 
of about four inches the two roads coincide, to again separate 
upon their downward course, the breath-road taking the 
anterior position and entering the trachea, through the larynx, 
and the food-road crossing to the rear and entering the oesoph- 
agus (see schema in Chapter I). The region in which the two 
roads are coterminous is called the pharyngeal space, the 
pharynx, or the throat. It is an irregularly shaped, hollow 
cylinder, decreasing in size from above downward and some- 
what flattened from the front to the back. Its inclosing wall 
comprises three layers, the outer muscular, the middle fibrous 
and the inner composed of mucous membrane, which for the 
upper third of its extent is covered by a ciliated epithelium and 
below that by one of squamous type. This threefold wall derives 
osseous support posteriorly from the cervical vertebras of the 
spinal column; in front it is strengthened and its contour 
preserved by attachments to the superior maxillary, inferior 
maxillary, sphenoid and hyoid bones. 

Five locative prefixes are used to describe parts of the pharyn- 
geal space; the naso-pharynx is at the top, adjacent to the 
nares, and is also called the pharyngeal vault; the meso-pharynx, 
immediately below this, is the central portion; the part joining 
the oral cavity is termed the oro-pharynx, and that directly 
opposite, along the posterior wall, the retro-pharynx; the 
lower extremity, at the orifices of the larynx and oesophagus, 
is named the laryngo-pharynx. These five terms do not signify 
separate areas with precise boundaries, but are employed, with 
some latitude of meaning, to describe regions in the open space 

1 68 



THE NASOPHARYNX 1 69 

inclosed by the pharyngeal walls, thus proving very convenient 
in discussing the surgical procedures within this territory. A 
similar elasticity of meaning applies to the statement that 
throughout the pharynx the breath-road and the food-road 
coincide. Every part of the space is reached by the air, both 
inspired and expired, but in the usual upright posture, morsels 
of masticated food pass backward and downward, without 
touching anything above the meso-pharynx ; nevertheless, the 
whole cylinder is accessible to them and by a change in posture, 
or by muscular spasm, they are readily thrown into the naso- 
pharynx so that it is properly included in the thoroughfare 
occupied jointly by the breath-road and food-road. 

The naso-pharynx, constituting the upper portion of the throat 
cavity, though continuous with the space below it and very 
similar in appearance, has, nevertheless, certain anatomical 
and physiological features, which give it a distinct character, 
exerting an influence upon morbid processes occurring in this 
region, so that they exhibit peculiarities not elsewhere observed. 
Among these distinctive features are the four orifices, the two 
nares opening upon the anterior aspect and the right and left 
Eustachian tubes upon the sides. These communications 
bring the naso-pharynx into very intimate association with the 
nose and the ears so that there is much interdependence in 
both health and disease. In addition, its mucous membrane 
has a ciliated epithelium, like that of the nasal fossae, and it 
cooperates in sterilizing the air entering by the breath-road. 
This kind of epithelium extends but little beyond the plane of 
the hard palate, the lower boundary of the naso-pharynx , the 
rest of the throat having the squamous variety. Here, also, 
the mucosa is supplied with numerous glands secreting mucus 
and, at the rear of the vault, these glands are of the racemose 
type and exist in such abundance as to form a thick layer em- 
bedded in the submucosa, an important fact in connection 
with the etiology of adenoid growths. As a consequence of 
these structural features some morbid conditions are so modi- 
fied in the naso-pharynx that it is most convenient to consider 



I70 NOSE, THROAT AND EAR 

them as diseases proper to this region, while others produce 
here the same manifestations as elsewhere and are best viewed 
as affecting a wide field, of which this is one part. 

Under the second head comes simple, acute, catarrhal phar- 
yngitis, a disorder whose manifestations are nearly identical 
in all parts of the throat. Causation, symptomatology and 
treatment may be considered as those of a single disease, whose 
variations are those of locality not of character. It will be 
subsequently discussed from this point of view. With the 
chronic form the case is different; here so much modification 
results from the peculiarities of the naso-pharynx that we have 
to deal with what is virtually a distinct malady; hence it is 
clearer and more logical to take up this disease by itself, des- 
ignating it by a distinctive name, significant of both its char- 
acter and locality; chronic naso-pharyngitis. 



CHAPTER XIV 
CHRONIC NASOPHARYNGITIS 

Chronic nasopharyngitis, called also postnasal catarrh, is a 
common affection which often begins insidiously and exists 
for a long time before being subjected to special treatment. 
It is usually a sequel of some abnormal condition in the nose, 
though the sudden and marked changes in temperature, char- 
acteristic of our climate, may also be a factor in the etiology. 
This is a very common opinion among the laity. 1 

The symptoms, in addition to a variable amount of discom- 
fort in the throat, are mainly due to the secretion of a liquid 
produced by the sub-acute inflammation ; a mixture in changing 
proportions of serum, mucus and pus. At night this accumu- 
lates in the naso-pharynx and in the morning its irritating 
effect prompts the patient to eject it. This he often finds 
difficult. The mixture is tenacious and adheres to the surface 
of the mucosa. It frequently gives to the patient the sensation 
that a foreign body is lodged at the junction of the nose and the 
throat. He makes violent efforts to dislodge the obstruction 
by swallowing, by forcible blowing of the nose, by persistent 
hawking and spitting. The natural result is nausea and some- 
times even vomiting. After many repetitions of such experi- 
ences some patients learn to dislodge the adherent mass by 
introducing a finger into the postnasal space. This, of course, 

1 This disease is one of a group of throat affections, for which the American 
climate is popularly held responsible. Young students, who expect to make 
singing their profession, are advised to live in southern Europe through their 
years at the music schools, so as to protect their voices from injury during the 
formative period. There are, however, some excellent vocalists, who never 
went abroad until maturity, but followed careful habits of healthful living. To 
accept the usual advice may prove profitable to vocal students — the plan is 
certainly profitable to the foreign teachers. 

171 



172 NOSE, THROAT AND EAR 

tends to sicken the stomach. During the day there is a dis- 
agreeable sensation that a liquid is falling, drop by drop, into 
the back part of the throat and this feeling pretty truly repre- 
sents what is taking place. 

The frequent and irrepressible impulse to clear the throat 
soon becomes very annoying to the patient and he feels painfully 
that he is growing repulsive to those around him. In time, the 
continual overaction of the pharyngeal muscles leads to much 
relaxation and to congestion of the velum palati; the tip of the 
elongated uvula tickles the fauces and thus serves to aggravate 
the trouble. 

The general health is apt to suffer in consequence of indiges- 
tion and disordered metabolism caused by the swallowing of 
muco-pus, a surprising quantity of which forms in the course of 
the day. The Eustachian tube and consequently the middle 
ear are often involved. Frequently the voice is affected in a 
way that is trying and, with professional vocalists, endangers 
their business. A singer, subjected to repeated interruptions 
by the necessity of clearing his throat, comes to lose confidence 
in his voice, dreading that it will fail him during a public per- 
formance, and the nervousness of fear impairs his control of 
the vocal organs. In addition to this, the swelling incident to 
the disease encroaches upon the space of the epipharyngeal 
vault, decreasing the resonance of the tones produced. This 
inferior quality shows itself particularly in the singing voice, 
simulating the effect of age, the calamity whose slightest sign 
alarms the public singer. For him, obviously the disease under 
consideration is a most serious matter. 

The morbid anatomy of chronic naso-pharyngitis includes 
an increase in the lymphatic and other glandular elements and 
also in the connective tissue together with a thickening of the 
mucous membrane and continuous engorgement of its capillaries 
with venous blood. The surface when inspected with the post- 
nasal mirror appears very red, congested, and in parts covered 
with thick, tenacious muco-pus. These appearances, together 
with the symptoms already described and the clinical history 



CHRONIC NASOPHARYNGITIS 1 73 

of the case are sufficient for a correct diagnosis. The patient, 
particularly if he makes professional use of his voice, is naturally 
very solicitous regarding the prognosis, not only as it concerns 
his health, but in regard to the conservation of his vocal powers. 
Assurance may be given that the prospect of complete recovery 
is good, provided the patient's habits are carefully regulated 
and provided the treatment is skilful and long continued. 

The therapeutic measures are both constitutional and local. 
Normal nutrition is to be promoted by a plain, nutritious diet, 
without luxuries, and elimination encouraged by exercise out 
of doors, and by baths, whose frequency and temperature are 
adapted to individual needs. There is a great diversity in this 
respect and the kind of baths which are beneficial can be de- 
termined only by trial. Constipation must not be permitted; 
the regulation of the bowels will depend mainly upon proper 
food; but inaction for more than twenty-four hours calls for 
prompt administration of a mercurial, or one of the salines. 
The under garments must be such as will absorb the cutaneous 
secretions and the patient's habitation, especially his bedroom, 
must be well ventilated. Alcohol and tobacco are interdicted. 
As to hours and methods of work, it is utterly futile to lay 
down any rigid directions. Excepting the leisure class, which 
in our country is very small, our patients, unless bedfast, are 
engaged in their various vocations and must conform their 
habits to the requirements of those callings. All that can be 
done by the patient, all that he should be asked to do, is to make 
the strain of his work as moderate as he can and to avoid un- 
healthful practices which are not a necessary part of his occu- 
pation. If any constitutional dyscrasia or diathesis exists, it 
should have appropriate treatment. 

The first in order of the local procedures is the correction 
of any abnormal conditions which may exist in the nose or 
tonsils, for these are often the cause of the nasopharyngitis 
and when they are rectified it tends to a gradual, spontaneous 
cure. The next step is to thoroughly cleanse the field of morbid 
action. To secure room, shrink the middle and lower turbinals 



174 NOSE, THROAT AND EAR 

with cocaine and epinephrin solution, then through the an- 
terior nares direct a spray upon the naso-pharynx so as to 
irrigate it in every part and to loosen, as much as possible, the 
adherent secretions. For this purpose employ DobelPs solu- 
tion (Chapter III) or a similar alkaline lotion. Then introduce 
through the anterior nares a cotton-tipped applicator and 
wipe out the naso-pharynx, dislodging all the tenacious muco- 
pus found upon the walls and carrying it away. Some patients, 
who are used to manipulations with their throats, acquire good 
control of their muscles and bear quietly what would in others 
excite violent gagging and coughing. In such tolerant throats, 
it is a good plan to introduce the applicator through the 
mouth, entering the vault from below. When inspection with 
the postnasal mirror shows that the walls of the naso-pharynx 
are thoroughly clean, they should be medicated with glycerine 
and tannic acid (four per cent, solution) the applicator passing 
through either the nares or the mouth. Following this, the 
spray of camphor and menthol (five grains of each in a fluid- 
ounce of liquid petrolatum) introduced by the nasal route 
should be used for three or four days. 

By this time, sufficient progress has usually been made to 
employ the iodine preparations. Of these Boulton's solution' 
(Acid carbolic, cryst. gr. xviij; Tr. iodini comp. fl. 5 j; Glycerini 
fl .§ jss ; Aqua dest. fl . 5 ij . M .) which is the mildest, should be used 
first. In a couple of days it may be succeeded by formula 
No. i, iodine, given in Chapter VII. This should be applied 
upon alternate days, until its effects are pronounced, its use 
being preceded, each time, by a thorough cleaning of both 
nose and pharynx. A two per cent, aqueous solution of alum, 
sprayed upon the fauces after each of these treatments, will do 
much to correct the congestion and relaxation of the velum 
palati, which are commonly present. Under these measures 
we may expect a gradual cessation of the morbid or excessive 
secretions, a return of the capillaries to their normal size, and 
catabasis of the adventitious cells whose presence has caused 
tumefaction of the walls and interference with the resonance 



CHRONIC NASO-PHARYNGITIS 1 75 

of the voice There may, however, occur at any time attacks 
of acute inflammation which will require intermission in the 
use of iodine and a return to sedative treatment, till they are 
subdued. In some hypersensitive cases, particularly when there 
is relaxation or ulceration of the mucous membrane, it is 
advisable to replace the iodine with a two per cent, solution 
of silver nitrate. In using either of these remedies with the 
applicator, care must be observed that the cotton tip is only 
moist, not dripping, as a drop falling into the larynx is liable 
to cause violent spasm and alarming dyspnoea. 

The plan of treatment above described has been found, in 
the writer's experience, best adapted to the cure of this disease, 
but neither it, nor any other, should be followed in a routine 
fashion. Every time the patient presents himself, the breath- 
road should be carefully examined and, if conditions have 
changed, the treatment should be altered accordingly. It is 
only thus that we may hope to bring about a restoration of the 
structures which have deviated so far from the normal standard. 

The naso-pharynx is sometimes affected by inflammation of 
an atrophic type whose symptoms resemble those described 
above. There is also similarity of appearance, but careful 
examination shows that the crusts are larger, dryer and of 
darker color. Their removal discloses a membrane which is 
dry, pale and glistening, not red and congested, as in the 
hypertrophic type. Upon this uncovered membrane are fre- 
quently found shallow ulcers of traumatic origin, due to the 
patient's efforts to remove the crusts with his fingers. The 
pathological process consists in the exudation of muco-pus of 
a peculiarly tenacious kind which rapidly dries into hard crusts ; 
beneath these takes place a structural change, the epithelial 
and glandular elements undergoing degeneration and finally 
disappearing, to be replaced by connective tissue of low vitality. 
The disease may be an extension of preexisting atrophic rhinitis 
or may be caused by long continuance of the hypertrophic 
variety. It may also arise in the course of anaemia, tuberculosis, 
or syphilis. Under judicious treatment the prognosis is good, 



176 NOSE, THROAT AND EAR 

as to checking further extension of the disorder, but the regenera- 
tion of the atrophied membranes is not to be expected. 

As to treatment, the presence of tuberculosis, syphilis, or 
other general disease, is an indication to administer the proper 
constitutional remedies. Topically, Dobell's or another alka- 
line solution, should be used to thoroughly cleanse the naso- 
pharynx, through either the mouth or nose. All crusts should 
be removed by a cotton-tipped applicator wet with an alkaline 
liquid. Ulcers are touched with a two per cent, silver nitrate 
solution and then the vault insufflated with powdered thymol- 
iodide. After the ulcers have healed, the stimulating and 
catabasic treatment is continued with the compounds of iodine 
and iodide of potassium. Three formulae are given in Chapter 
VII. As home treatment, the patient is instructed to irrigate 
the naso-pharynx several times daily with a solution which is 
both alkaline and alterative; one of the best combinations being 
a pint of normal salt solution with the addition of fifteen drops 
of the tincture of iodine. This is not at all strong and, after 
it has been used a short time with good effect, it may be strength- 
ened, little by little, until finally thirty drops of the tincture 
are added to the pint of salt water. 



CHAPTER XV 
ADENOIDS 

Adenoids are enlargements of the lymphoid tissue which 
always exists upon the upper, posterior wall of the naso-pharynx. 
To this growth has been applied the name, Luschka's tonsil, 
because it was first fully described by that anatomist, and also 
the term, pharyngeal tonsil, in contradistinction from the 
single lingual tonsil and the pair of f aucial tonsils. This growth 
varies from a slight coniform elevation above the mucous mem- 
brane to a large and usually segmented mass, entirely obstruct- 
ing the postnasal orifices and thus completely occluding the 
breath-road. 

Most cases occur between the third year and puberty, but 
the condition has been observed in the first year of infancy and 
even at birth. At puberty, adenoids tend to decrease spon- 
taneously and even disappear, because at this period the bones 
of the face develop rapidly causing a great increase in the size 
of the breath-road, and also because of the tendency manifested 
at this time for all lymphoid tissues to undergo a retrograde 
change with shrinkage and partial atrophy. The natural 
tendency toward the development of adenoids during the periods 
of childhood and youth is supplemented by the influence of 
infections and hence these growths are often observed subse- 
quent to attacks of measles, scarlatina, diphtheria, and rotheln. 
They are also prone to take place in those affected with tuber- 
culosis and syphilis and are very common in bottle-fed children 
and among the neglected and poorly nourished. 

Symptoms of the earliest stage are apt to be overlooked or, 
if observed, misinterpreted. When the child is brought to the 
physician, it is usually on account of marked mouth breathing; 
loud snoring during sleep; incipient deafness; or such mental 

12 177] 



178 NOSE, THROAT AND EAR 

dulness as causes him to fail in his examinations at school. 
By this time the disease is fully developed. Its pathology is 
comparatively simple: the characteristic feature is the over- 
growth of a group of lymphoid cells, held together by a network 
of connective tissue, through which capillaries, more or less 
tortuous, extend their ramifications. Interspersed among these 
cells are a number of mucous glands and there is intermittent 
exudation of serum and mucus, which drops down into the 
oesophagus. The lymphoid mass, if it attain any considerable 
size, assumes a plicated or racemose form, hanging downward 
and forward across the entrance to the nares, which may be 
slightly obstructed, or entirely closed. A hypertrophic body 
of this sort would not, in some situations, give much trouble, 
but located at the curve of the breath-road, it produces a symp- 
tom-complex of wide extent and great importance. The con- 
dition of sub-acute inflammation existing in the naso-pharynx 
extends to contiguous structures, causing rhinitis and increas- 
ing the adolescent liability to epistaxis, or following an upward 
course affects the mucosa of the Eustachian tubes and subse- 
quently that of the middle ear. Otitis media may also result 
simply from the pressure of the growth against the Eustachian 
orifice, whose closure stops the aural ventilation and drainage. 
Either sequence may damage the hearing. If the invasion of 
contiguous structures takes an anterior direction, the faucial 
tonsils and the uvula will be affected. Concomitant with the 
involvement of the faucial tonsils, appears a granular pharyn- 
gitis, produced by the same process of extension. The mucosa 
becomes red and congested, while frequently long strands of 
purulent mucus are seen hanging from the naso-pharynx along 
the posterior wall. Gastric digestion may suffer from muco- 
sero-pus which finds its way into the stomach and mingles with 
the peptic secretions. The indigestion is made worse by the 
practice of rapid eating to which the child is almost forced, 
because the occupation of the food-road, while mastication and 
swallowing go on, stops his respiration and he satifies his hunger 
by bolting the food as fast as possible, so as to resume breath- 



ADENOIDS 179 

ing. Of course, this remark applies to cases in which the normal 
breath-road has been occluded and the only way to the lungs is 
through the mouth. 

Mouth breathing is a characteristic sign of large adenoids; 
when long continued it produces a peculiar physiognomy 
which is typical, and nearly sufficient for diagnosis without 
other signs. It is also followed by many anatomical changes 
whose occurrence is made possible by the youth of the patients, 
their structures, including the bones, being in the stage of de- 
velopment and subject to alterations which would be im- 
possible at a later period of life. The disuse of the nostrils 
for their natural function of breathing prevents their normal 
development and they have a pinched, narrow look; this makes 
the bridge of the nose appear wider than it really is. Faulty 
growth of the superior maxillary bone produces a common 
anomaly, a high, narrow vault of the hard palate, termed from 
its shape, "the Gothic arch," and, for the same reason, the 
upper incisor teeth project forward, so that they are not fully 
covered by the upper lip. Habitual lack of an adequate sup- 
ply of air stunts the development of many structures. There 
is lack of muscular strength and of nervous energy; the un- 
expanded chest is flat and the shoulders have a forward stoop 
which in children partly deaf is emphasized by leaning toward 
a speaker, in the effort to hear. The general lowering of vitality, 
consequent upon the imperfect oxygenizing of the blood, makes 
the patient peculiarly susceptible to tonsillitis, diphtheria, laryn- 
gitis, bronchitis and the protean forms of tuberculosis. Cervical 
adenitis is common, both on account of the impaired power of 
resistance and the ready absorption of diseased products of the 
adenoids, through the lymphatics. Insomnia, night terrors, 
enuresis and some forms of chorea have been shown to be sequels 
of neglected adenoids, even epilepsy has been placed in this 
category and, though one should be cautious in making asser- 
tions regarding the etiology of this grave disease, there is proof 
that in some cases epileptiform seizures, which had become 
chronic, have ceased after adenoidectomy. Both voice and 



i8o 



NOSE. THROAT AND EAR 



speech are frequently affected : the vocal resonance is lessened 
by the growth's encroachment upon the vault of the naso- 
pharynx and restriction of the normal movements of the velum 
palati^interferes with the articulation of certain sounds, par- 
ticularly the liquids m and n, which the patient changes to the 
corresponding mutes, b and d. 

The psychic symptoms are of especial interest. Diminished 
nutrition of the brain, dulled hearing, disordered metabolism 




Fig. 66. — Case of nasal obstruction from adenoids, showing characteristic, dull, 
facial expression. 



and general asthenia combine to impair the mental power of 
those suffering from adenoids and, in the past, before their 
malady was understood, they were considered intellectually 
deficient: backward, stupid children, close to the border line 
of the mentally defective. These children have a dull, listless 
expression of face, the features sometimes taking on a mask- 
like immobility. Their speech is slow and imperfect in articu- 



ADENOIDS 



181 



lation; their movements lack the sprightliness natural to child- 
hood; the feet are raised but little in walking and often dragged; 
while in the worst cases there are signs of muscular incoordina- 
tion. At school, they cannot keep up with their fellows and 
drop out of the classes, so that they remain year after year in 
the same grade. 




Fig. 67. — The patient shown in Fig. 66, six months after removal of adenoids. 
The normal facial expression is entirely restored. 



The illustrations here presented show a vivid contrast be- 
tween the normal countenance and the dull, listless, facial 
expression produced by adenoids. Fig. 66 reproduces the 
photograph of a boy in whom the breath-road had been seri- 
ously obstructed by adenoids. Observe the open mouth, the 
pinched nostrils, the stolid, stupid expression of the face. 
Fig. 67 portrays the same lad, six months after removal of the 
adenoids. He has completely regained the normal appearance 



182 NOSE, THROAT AND EAR 

of his face; the lips are closed and there is the harmony of fea- 
tures and vivacity of expression natural to an active, intelli- 
gent boy of his age. 

These unfortunate children afflicted with adenoids were in- 
strumental in bringing about a great and beneficent change in 
modern education, for the wonderful improvement in their 
mental condition, which followed the removal of the growths, 
powerfully influenced pedagogical thought and led many of the 
best teachers to accept as a basic principle, that the first thing 
in a course of education is to ascertain whether the pupil is 
physically and mentally normal; so that he can benefit 
by the instruction to be given. The state of his body 
must be learned by medical examination and if morbid con- 
ditions exist, they must, if possible, be corrected. At the start 
of any proper plan of teaching there must be conference between 
the teacher and the physician. As has been pithily said, 
"For the mouth-breathers, the keen curette did more in five 
minutes than the keen pedagogue in five years." 1 

The diagnosis of adenoids can usually be made by the 
symptoms alone, but it is desirable, in every case, to make a 
rhinoscopic examination, to dispel any possible doubt regarding 
the presence of the growth and also to ascertain its size, shape 

1 The cartoons in Punch (London) and other illustrated papers have 
depicted every type of physiognomy and, among the pictures of stolid school- 
boys, "dunces, blockheads," are faces which might well be transferred to medical 
text books as portraits of mouth-breathers. Such unlucky boys were the butt 
of ridicule for their schoolmates, and older people often misjudged their stolidity 
and considered them disrespectful and stubborn. A lad of this sort fared 
badly in the oldtime school. He was given a task, told to "mind his book" 
and, when he failed to "commit his lesson," received condign punishment. The 
schoolmaster gave him a sound thrashing and then made him stand in a corner, 
with his face to the wall and his head crowned with a conical cap of white paper, 
bearing in large black letters the word, "Dunce." When the times grew more 
humane, flogging and dunce cap fell into disuse, and the backward boys 
were segregated in special schools. Here they were made the subject of various 
pedagogical experiments; monitor teaching; object teaching; Froebel's kinder- 
gartening; all sorts of things, except the right one; until at last medical science 
interfered and gave the boys what proved the panacea for their ills — the chance 
to breathe. 



ADENOIDS 183 

and other qualities. A few drops of a two per cent, solution 
of cocaine in the anterior nares will not infrequently so shrink 
the turbinals that, through a nasal speculum, we may see the 
adenoids as pale, glistening masses hanging from the vault of 
the naso-pharynx; when the patient swallows these masses rise 
and move forward into the nasal fossa; posterior choana. In 
many instances the adenoids can be seen reflected in the post- 
nasal mirror. If neither anterior nor posterior rhinoscopy 
gives a satisfactory view, we must resort to digital palpa- 
tion. This is an unfailing diagnostic procedure, but it is un- 
pleasant and it is advisable for the surgeon to give a prior ex- 
planation of just what he intends to do. The patient, with 
mouth well opened, sits upon a low-backed chair, the surgeon 
standing behind, uses one hand to press the cheek between the 
upper and lower teeth, a precaution against their biting the 
examining finger; then the index-finger of the other hand is in- 
troduced through the mouth, passing to one side of the uvula, 
and going up into the naso-pharynx. This cavity is thoroughly, 
but gently, explored and, if adenoids be present, the finger will 
be covered with blood, for the membrane enveloping the growth 
is thin, friable and bleeds very easily. Adenoids feel like a soft, 
gelatinous mass ; the sensation imparted to the finger is peculiar 
and characteristic; when once experienced, it is afterward easily 
recognized, though unfortunately we have no distinctive word 
which describes it accurately. In this and many other in- 
stances, our nomenclature fails to furnish terms to adequately 
express our ideas. 

When the diagnosis has been established by visual or digital 
examination, choice must be made among plans of treatment. 
There is seldom any doubt upon this point, for in the vast 
majority of cases, adenoidectomy is far better than anything 
else. In competent hands, this is a safe operation and the 
risk of recurrence is so slight that it may be disregarded. There 
is a partial exception in the case of very young children and 
their parents should be warned that an attack of some infec- 
tious disease, particularly measles, may produce another adenoid. 



184 NOSE, THROAT AND EAR 

Haemophilia is acounterindication to this, as to all other cutting 
operations, and weak, anaemic children, together with those 
suffering from syphilis, tuberculosis, or other constitutional 
disease, should undergo a course of roborant treatment pre- 
paratory to the operation, so that it may confer the greatest 
benefits. Counting out the few cases to which these cautionary 
remarks apply, we may confidently advise the thorough ex- 
tirpation of adenoids, both for the relief of the palpable obstruc- 
tion of the breath-road, and for the far reaching effects upon 
many organs and many functions; there are, indeed, few surgical 
procedures which have to their credit so many beneficent 
results. 

Thoughtful attention to all preliminary details will do much 
to secure a successful, well-finished operation. As a precaution 
against profuse haemorrhage and as affording a better chance to 
complete the work at one time, I prefer general to local anaes- 
thesia. The inhalation of ether is usually very satisfactory, 
for if the patient has been properly prepared, the nausea and 
other unpleasant sequels are reduced to a minimum and there 
is very little danger of postoperative accidents. It must be 
remembered that the patients are young and free from those 
degenerative changes which, in the later stages of life, often make 
general anaesthesia unsafe. 

Upon the day before that fixed for the operation, the blood 
should be subjected to the coagulation test and the urine ex- 
amined. If the patient's general condition appears to be 
normal, he should take a cathartic at bed time and this should 
be supplemented, if necessary, by an enema, the following 
morning, the object being to have the alimentary canal empty. 
With this end in view, no solid food should be taken upon the 
day of operation, any craving of hunger being relieved by milk, 
and even this should be avoided for a prior interval of three 
hours. The bladder should be emptied just before the anaes- 
thetic is given. If the operating table can be placed near a 
large window or under a skylight, so that direct rays may enter 
the naso-pharynx, it will be possible to work by sunlight, other- 



ADENOIDS 185 

wise use must be made of artificial light, reflected from the head 
mirror. The table should have a head piece which can be 
lowered; if this is lacking, the patient's body must be raised 
(folded blankets or other extemporized support) so that the 
naso-pharynx will be on a lower level than the larynx, when the 
patient lies upon his back. The purpose of thus elevating 
the chest is to hinder blood from entering the larynx and the 
neck need not be bent far back; for a slight difference of level 
will prevent any escaping liquid from going into the trachea and 
turn it into the oesophagus, lying immediately underneath. 

With the patient extended in the dorsal posture, with 
lowered head, the jaws are widely separated and a mouth- 
gag inserted between the teeth; then the surgeon's index-finger 
is introduced into the naso-pharynx, to make a final exploration 
and to corroborate, or correct, the findings of previous examina- 
tions, as to position, size and attachments of the growth. The 
finger is now withdrawn and a non-fenestrated tongue-depressor, 
held in the left hand, is used to draw the tongue forward and 
retain it in that position, in order to secure an unobstructed view 
of the fauces and the posterior wall of the pharynx. Holding 
the closed Brandegee forceps in his right hand, the surgeon 
introduces the instrument upon its side, so that the curved 
blades pass through the fauces with their points directed toward 
the right wall of the mesopharynx; the shafts of the forceps 
traverse the mouth, and the curved handles project across the 
cheek, pointing toward the patient's left ear. When the blades 
reach the retropharynx, the handles are moved through an 
arc of ninety degrees, taking their place in the median line, in 
front of the chin, and this motion rotates the shafts and raises 
the blades to an upright position in the naso : pharynx posterior 
to the velum palati. The forceps blades are now separated, 
pushed further back and brought toward each other, grasping 
the growth, their sharp edges sink into the mass, which is 
gradually severed from its attachments by a rocking, twisting 
motion of the handles. Position of forceps is shown in Fig. 68. 
The purpose in view is to remove as much of the mass as possible 



i86 



NOSE, THROAT AND EAR 



with the forceps and, when it is of moderate size and has fairly 
well-defined edges, nearly all may be engaged in the fenes- 




FiG. 68. — The Brandegee forceps grasping a mass of adenoid. 
\ 




Fig. 69. — Removal of Adenoid completed with curette. 

trated blades and brought away, when the instrument is with- 
drawn from the mouth. This is a very satisfactory result 



ADENOIDS 187 

which cannot always be obtained, for the growth may have 
fringe-like adhesions upon the pharyngeal wall below and also 
laterally. In such cases, we must be content to have the forceps 
remove the upper and anterior part and to complete the work 
with the curette which should scrape away all the morbid 
tissue, caution being used, of course, to prevent injury to normal 
structures. The Eustachian eminences can be avoided by 
keeping the shafts of the forceps and curette in the median line 
and the nasal septum will not be endangered if the shafts are 
raised close to the upper incisor teeth. The curette in situ is 
shown in Fig. 69. 

After the curettement, the index-finger is again introduced 
and any adhesions to the Eustachian eminence, or elsewhere, 
are broken down; if this examination discloses any remnants of 
the growth, these must be cleared away with the curette. 
After these procedures, a long, curved haemostat holding a piece 
of picked gauze, is introduced and sufficient pressure made upon 
the surface, denuded by the operation, to control the bleeding. 
This can usually be done in three or four minutes, when the 
gauze may be removed. The patient is returned to bed where 
he should remain for twenty-four hours. For twice that length 
of time, use should be made of a special diet, very bland and 
unstimulating, after which there may be a gradual return to the 
food habitually taken. No further local treatment is usually 
required. 



CHAPTER XVI 
NASOPHARYNGEAL NEOPLASMS 

The neoplasms found in the naso-pharynx may be of either 
the benign or the malignant kind and they appear to depend 
upon the same causes, which produce similar growths in the 
nose. On account of the anatomical features of this region, 
there are some symptoms, which are common to all nasopharyn- 
geal tumors. There is obstruction, slight or serious, to respira- 
tion, the voice is altered by encroachment upon the vault, the 
patient has a more or less persistent inclination to clear his 
throat of mucus or muco-pus, whose presence is due to the 
coincident catarrh, and he often feels as though a foreign body 
were lodged between the nose and throat. Sleep is apt to be 
restless and accompanied by snoring; hearing is frequently 
impaired upon one or both sides, either by the extension of 
catarrh to the middle ear, or by pressure on the Eustachian 
tubes. As the tumor grows larger, its anterior extension may 
bear against the soft palate, embarrassing its functional move- 
ments and making swallowing difficult; pari passu with this 
growth, interference with normal breathing increases and air 
must be admitted through the mouth. Very large tumors of 
firm, dense consistency may produce erosion of surrounding 
tissues and even cause absorption of the bony walls subjected 
to their pressure. In malignant growths, the symptoms 
mentioned are supplemented by pain, recurrent haemorrhages, 
f cetor of the breath, enlargement of the cervical glands and the 
cancerous cachexia; the last two signs appearing in an advanced 
stage and indicating metastatic infection. 

Differential diagnosis depends chiefly upon posterior rhinos 
copy and digital exploration. Polypi (Fig. 70) which are fre- 
quently encountered, are reflected in the postnasal mirror as 



NASOPHARYNGEAL NEOPLASMS 



pyriform bodies, pale in color and semi-translucent; to the 
finger they impart the sensation of smooth, soft, yielding masses, 
moving readily on account of the flexibility of the pedicle, which 
holds them. Fibromata, also very common, are dense, highly 
vascular tumors, composed mainly of connective tissue. In the 
mirror they show a dark red color and a surface marked by 
furrows, or lobulated; to the digital touch they seem hard, 
firm, almost immovable. They often grow to a large size and, 
though not primarily malig- 
nant, are apt to undergo a 
cancerous degeneration. 

Among the less common 
benign neoplasms are pa- 
pillomata, chondromata 
and adenomata. The ma- 
lignant type is represented 
by sarcoma and carcinoma, 
which have the same char- 
acteristics in the naso- 
pharynx as in other situa- 
tions. If the diagnosis is 
not positive, if there is a 
shadow of doubt regarding 
the nature of the tumor, 
local anaesthesia should be 
induced and a specimen cut from the growth and at once ex- 
amined for the evidence of malignancy. As the only possible 
hope lies in very early extirpation, it is wholly unjustifiable 
to wait until haemorrhage, pain and involvement of the cervi- 
cal glands establish a symptomatic diagnosis. 

The only rational and efficient treatment for tumors of the 
naso-pharynx is their thoroughgoing removal. In many cases, 
this can be done with the cold wire snare. In children general 
anaesthesia is required, but the local method answers very well 
for those who are older. The wire snare is to be introduced 
through either the nose or mouth and brought into a position 




Fig. 



70. — Fibrocystic polypus in vault of 
the pharynx. 



190 NOSE, THROAT AND EAR 

where its loop can be passed over the tumor so as to encircle 
it. This adjustment of the loop is aided by manipulation of the 
postnasal mirror; or by the surgeon's index-finger. The loop 
should be carried up over the tumor's pedicle or other at- 
tachment, as close as possible to the base, and the morbid mass 
dissevered by gradual constriction of the encircling wire. 
After the part ablated by the snare has been withdrawn through 
the mouth, any remainder is removed with biting forceps, or 
a curette. Sessile or very small growths, which cannot be en- 
gaged in the loop of the snare, can be scooped out by a sharp 
curette. The postoperative treatment is similar to that fol- 
lowing adenoidectomy. 

In large malignant tumors and in some non-malignant 
growths, which have been neglected until they have attained 
a great size, it may be impossible to effect removal through 
the natural passages and the only alternative is resection of 
the upper jaw, making an opening through the hard and 
soft palate large enough to permit the separation of the tumor 
from all its attachments and the extirpation of every particle 
of morbid tissue. This is an extensive and difficult opera- 
tion and should not be undertaken without fully consider- 
ing, and frankly explaining to the patient, the risks involved. 
No skill or prudence can eliminate the dangers of death from 
shock; from asphyxia, from haemorrhage, or from pneumonia. 
Nevertheless, in the absence of malignant infection of the 
system, this operation is justifiable and, in a number of cases, 
has saved the patient's life and, together with plastic restora- 
tion of the upper jaw, has secured for him freedom from suf- 
fering and a state of comparatively good health. 

Where malignant infection of the system has already taken 
place, surgery can accomplish nothing. Our only resource is 
to adminster narcotics, particularly opium and its alkaloids, 
to diminish, as far as possible, the patient's sufferings; to gain 
for him the mitigation of euthanasia. 



CHAPTER XVII 
PHARYNGITIS 

The part of the throat below the naso-pharynx is the narrower 
section of the cylinder giving coincident passage to the breath- 
road and food-road. It joins the mouth through the arch 
of the fauces, the largest of the seven pharyngeal orifices, 
and at its lower extremity connects with the larynx and the 
oesophagus, the latter tube being a continuation of the cyl- 
inder reduced in size. Anatomically this section is very simi- 
lar to the naso-pharynx (Chapter XIII) except that its 
epithelium is squamous, instead of ciliated, and the mucous 
glands so numerous above the plane of the palate are here more 
sparsely distributed. The chief function of the pharynx is 
to furnish a warm, moist, resilient passageway for solids, 
liquids and gases upon their course to the lungs or the stomach. 

The mucosa and underlying tissues are often the site of 
various inflammatory affections, whose predisposing causes 
are numerous, but whose chief excitants are sudden reduc- 
tions in temperature and abrupt changes in atmospheric 
pressure, producing marked contrast between densities in- 
side the body and those outside. It is this barometric change 
which puts a strain upon the mucosa, which is a thin parti- 
tion between the intrasomatic and extrasomatic spheres of 
pressure; and this strain produces most of the effects popularly 
attributed to dampness. The climate of the eastern and 
middle states, which is noted for great and rapid changes in 
both the thermometer and barometer, is conducive to phar- 
yngeal disorders and it is not strange that they are common: 
indeed, as one author remarks: "When we consider that air, 
food, and drink of all kinds, and at many temperatures, enter the 
pharynx and also remember the climatic conditions, we are 

191 



192 NOSE, THROAT AND EAR 

not surprised that so many persons have sore throats, but 
rather that so many escape." 

Among people of American stock these pharyngeal affections 
are less prevalent than during the first half of the last century, 
as is shown by the medical literature of that time. The 
change is doubtless due in part to more hygienic habits of 
life, particularly to the disuse of the neck cloth of many folds, 
long in fashion, which kept the throat muffled up in a very 
irrational way; but I think it largely depends upon a racial 
tolerance gradually acquired, by which the body gains a certain 
immunity in regard to climatic influences. Emigrants from 
the south of Europe, where the climate is comparatively uni- 
form, are very liable to these disorders, which were quite rare 
among them in their old home. 

Pharyngitis may exist alone, or may be associated with 
rhinitis or tonsillitis; in fact, with inflammation of any, or 
all, parts of this region, where morbid processes find ready 
means of extension by continuity of surface. Predisposing 
causes are the rheumatic and gouty diatheses, sedentary habits 
with lack of muscular exercise, alcohol and tobacco, inadequate 
ventilation, especially of sleeping apartments, and whatever 
impairs gastrointestinal digestion, leading to imperfect metabo- 
lism and the production of enterogenous toxins. The in- 
fectious diseases, such as syphilis, tuberculosis and influenza 
produce manifestations in the pharynx, which are more log- 
ically enumerated among local exhibitions of the constitu- 
tional malady than among "etiological factors of the throat 
affection. Improper use of the voice is really an exciting 
cause, whose influence is limited to public N singers, speakers 
and others who make occupational use of the vocal organs. 

In the acute or catarrhal type of the disease, the first 
symptom noticed by the patient is dryness of the throat. 
This is sometimes recognized as the aggravation of an un- 
comfortable sensation habitually present, the patient de- 
claring that his throat is always dry, but now feels parched. 
This symptom merits special attention, for the habitually 



PHARYNGITIS 1 93 

dry throat, the mucosa sicca, is often an early sign of Bright's 
disease, or of diabetes. It may have other origin, but it 
should prompt inquiry regarding these maladies, at least the 
taking of the blood pressure and the tests for albumen and 
for diabetic sugar. Together with the feeling of dryness, 
there is a sense of rigidity as though the muscles of the throat 
and neck were stiff, though the actual decrease of motility is 
slight, far less than in torticollis. To these symptoms there 
is soon superadded pain. While the muscles are at rest 
this is usually dull and is often described as a deep-seated sore- 
ness; but it is increased by muscular action, so that swallow- 
ing, coughing and speaking may render it quite acute. The 
voice takes on a more or less harsh,, muffled quality, due, in 
part, to the patient's fear of pain, which makes his voluntary 
phonation imperfect, and in part to some extension of the in- 
flammation to the larynx. There is usually a rise in tem- 
perature of from one to three degrees with a corresponding 
acceleration of the pulse. Pharyngoscopy shows, during 
the first stage, a dry, tense, glazed surface; later, when secre- 
tion has been established, the mucous membrane is bright 
red with adherent patches of mucus, or muco-pus. If the 
uvula be involved, its loose cellular tissue becomes cedema- 
tous, imparting a sensation that there is a foreign body in 
the fauces, so that the patient makes repeated, though futile, 
efforts to clear his throat. The uvula may increase to such a 
size as to threaten suffocation and to necessitate lancing or 
amputation. When the inflammation begins to decline, the 
stages of recovery are similar to those observed in deferves- 
cence, wherever mucous tissues are concerned. 

In treatment, constitutional measures should be prompt and 
decided. The time-honored teaching, that at the outset of all 
acute diseases the alimentary canal should be cleared, is espe- 
cially pertinent here, because pharyngitis is nearly always 
associated with faulty digestion and disordered metabolism. 
A tablet containing half a grain of calomel and two grains of 
sodium bicarbonate should be administered each hour, until 



194 NOSE, THROAT AND EAR 

four have been taken. These are to be followed by a saline 
whose strength should be adapted to the patient's suscepti- 
bility (in which individuals differ widely) so that there may be 
free, but not drastic, catharsis. The patient should go to bed 
and remain in a state of entire physical and mental inactivity, 
until the return of a normal temperature signalizes deferves- 
cence. A warm bath during the first four hours is a useful 
adjuvant. In mild cases this treatment is often all that is 
required. Patients may refuse to go to bed because they 
think they are but slightly ill and cannot afford to interrupt 
their work, but this method of elimination and quiescence is 
the rational plan and, as such, saves time, suffering and danger. 

When the attack is of a. graver sort and does not yield readily, 
its persistence often depends upon changes in the blood due to 
disordered metabolism. Sodium salicylate, ten grains, may be 
given at intervals of four hours, and fifteen grains of potassium 
citrate, largely diluted, two hours after the other dose, until 
correction of urinary hyperacidity shows that the remedies 
are taking effect. If temperature goes above 102 F. tinct. 
aconiti rad. TTL x, two or three times during the twenty-four hours 
will be found useful. Ten grains of Dover's powder at night 
will generally alleviate the pain in rheumatoid cases, but in 
very sensitive patients who are kept awake by suffering, it is 
better to administer a sixth or a fourth grain of morphine hypo- 
dermically, than to subject them to the depression of pain and 
insomnia combined. The diet throughout must be bland, 
unstimulating and of laxative tendency; plenty of water should 
be taken and active elimination by the kidneys maintained. 

Local treatment is required in all cases, except those which 
yield promptly to rest and purgation. The cold compress 
upon the throat often diminishes the pain. An alkaline wash, 
such as Dobell's solution, should be used as a spray within 
both throat and nose, to cleanse the membranes from tenacious 
secretions and to promote resolution. Benefit will be derived 
from the use of lozenges, which by gradually dissolving, keep 
their ingredients in prolonged contact with the affected tissues. 



PHARYNGITIS 1 95 

Either of the following may be employed: Tine, ferri chlor. 
Tfl, j; potas. chlorat., potas. bromid. aa gr. ijss; M. — -Ext. 
kramerias gr. ijss, cocaine hydrochlorat, gr. }{ 2 , potas. chlorat. 
gr. ijss; M. For oedema of the uvula the solution of epine- 
phrin chloride, i: iooo should be used; if it fails, the distended 
membrane should be scarified. 

Chronic pharyngitis, called also hypertrophic, granular, or 
lacunar pharyngitis, and clergyman's sore throat is essentially 
a prolongation of the catarrhal form, with the addition of 
features resulting from continued congestion of the mucous and 
submucous tissues. It is very frequent in patients who, 
having an acute attack, resume their occupation and discontinue 
treatment before their cure is complete. This is often done 
in accordance with the mistaken notion that one can " light 
down," a disease, a prolific cause of chronic and incurable 
disorders. 

The morbid conditions present in this type of pharyngitis are 
those infiltrations and hypertrophies which result from long 
continued congestion. They closely resemble the intranasal 
alterations following protracted rhinitis, already considered, 
with the special feature that the tubular glands of the pharynx 
become filled with a caseous exudation and together with the 
enlarged lymphoid cells surrounding them form nodules which 
appear as slight, rounded elevations above the surface of the 
mucous membrane. There is also beneath the mucosa a 
proliferation of connective tissue. The symptoms include con- 
tinual discomfort in the throat and a tendency to hawking and 
coughing, sometimes with and sometimes without, expectora- 
tion; an unpleasant odor of the breath and considerable change 
in the quality of the voice which also shows marked weakness 
upon any attempt at prolonged vocalization, in either speaking 
or singing. 

In this disease much importance attaches to a thorough and 
patient study of the etiology. Many causes may contribute 
to its production and it is only by their discovery and by appre- 
hension of their influence, as etiological factors, that we can 



I96 NOSE, THROAT AND EAR 

formulate a rational plan of treatment. One group of causes 
is occupational. Where men work in an atmosphere charged 
with smoke, dust, sand, or the fumes of volatilized chemicals, 
some throats will be affected to various degrees, though some 
suffer little, or nothing. We cannot expect cessation of effects, 
if a cause continues to act, hence pharyngitis due to the in- 
halation of irritants, such as those mentioned, cannot be cured 
unless there is a change in occupation. Among occupational 
causes stands the improper use of the voice, 1 a subject of much 
interest, since it was long regarded as the chief reason for 
lacunar pharyngitis, bringing into general use the Latin and 
English synonyms : dysphonia clericorum, and clergyman's sore 
throat. In the first half of the 19th century, this disease was 
so prevalent that if a minister relinquished preaching, his act 
was commonly attributed to "throat trouble" and, in some 
denominations, more than forty per cent, of the pastors were 
reported as more or less afflicted in this way. Only a small 
fraction of that number are now attacked by the disease and so 
great a change points to some radical difference between the 
antecedent conditions in that period and our own, but no one 
appears to have found, or at least published, an adequate ex- 
planation. The rheumatic and gouty diatheses also play a 
part in the etiology and cases are reported where long-continued 
residence at Carlsbad and other spas for rheumatic patients 

1 A study of vocalization, as practised in different occupations, constrains one 
to think that no harm is done to the throat by long-continued speaking, by loud 
speaking, or by out-of-doors speaking, provided a proper method of phonation be 
discovered and pursued. Many clergymen are (or were formerly) sufferers 
from lacunar pharyngitis, attributed to their preaching three or four times 
weekly, although the aggregate length of their sermons was not over two or three 
hours; yet the auctioneer speaks in loud tones for several hours, each working 
day, and seldom incurs any injury. The street vendor, whose peculiar, nearly 
inarticulate cry may be heard for two blocks, uses his voice all day long, out of 
doors, in all weathers, yet at night-fall, he is not sick, nor even hoarse. This 
man knows nothing of anatomy or physiology, but he has, in some way, developed 
a method of phonation which enables him to avoid injury. If these vendors 
substitute plain, comprehensible speech for their peculiar, sing-song cry, they 
tire in an hour of two; but, with it, can go on all day. The reasons for this 
deserve more investigation than they have received. 



PHARYNGITIS 1 97 

has brought about the cure of pharyngitis, which had resisted 
all topical medication. Finally nasal and naso -pharyngeal 
obstructions and abnormalities are important causative factors, 
and deflections, deformities and hypertrophies should receive 
surgical treatment; very often their correction is the precursor 
of rapid improvement in the pharynx. 

In addition to the therapeutic measures indicated by what 
has just been said of the etiology, there are several topical 
remedies whose employment in connection with constitu- 
tional and surgical procedures will do much good, although 
when used alone, their effect is in the main palliative. Clean- 
liness should be secured and maintained by spraying the 
pharynx with an alkaline solution, e.g., DobelPs. When there 
is much relaxation, a solution of alum, ten grains to the fluid- 
ounce, proves a good astringent spray. A more active treat- 
ment consists in using upon a cotton-tipped applicator a so- 
lution of silver nitrate, ranging in strength from two to six 
per cent, according to circumstances or the iodine solution 
No. i described in Chapter VII. In cases of long stand- 
ing the tubular glands and the lymphoid cells upon their 
walls have degenerated to such an extent that they should 
be extirpated. When this is to be done, the protruding nod- 
ules, indicating the location of the glands, should be desensi- 
tized by several paintings with an eight per cent, solution of 
cocaine and then desiccated by the galvanocautery electrode 
at a cherry-red heat. Only a few nodules should be devitalized 
at one sitting. Chromic acid or the curette may be used 
instead of the cautery. The denuded spots, under the eschar, 
heal by granulation; during this process the proximity of irri- 
tant substances should be prevented, as far as possible. 



CHAPTER XVIII 

THE UVULA 

The uvula is a slender coniform process with its base at- 
tached to the center of the soft palate. It is free and pendu- 
lous occupying the middle of the oropharyngeal orifice and 
approaching within half an inch of the tongue, when the 
head is erect. It has a covering of mucous membrane with 
squamous epithelium and interiorly consists of a cellular 
substance traversed by strands of connective tissue and fibers 
from several muscles, the more important being the levatores 
palati and the tensores palati. Its blood supply comes from 
small arterial and venous branches (palatine) but these become 
recurrent several millimeters short of the free extremity, the 
lower segment having only minute capillaries; so too the 
terminal part is devoid of muscular fibers. These anatomical 
peculiarities are important pathologically and surgically. 
In cedema of the uvula, the serum which distends the pendu- 
lous bulb, extending to the mesopharynx or beyond, does not 
come from the coats of the bulb itself, but from the vessels 
higher up whose leakage gravitates to the lowest point, and 
an incision through the walls of this bulbous sack, while giv- 
ing vent to the imprisoned serum, will draw but little blood, 
if the cut extends no higher than the boundary of the lower 
segment comprising a third of the length. The uvula is some- 
times very short on account of arrested development. Some- 
times there is bifurcation in the median line, a cleft extending 
from the apex to the base. This is a slight manifestation of 
the anomaly which in its serious form constitutes cleft 
palate or hare-lip. These deformities result from failure of 
the two halves of the palatine structures to unite, as they 
do when development is normal. Persons with very short 



THE UVULA 199 

or bifurcated uvulas appear to suffer but little inconvenience. 
They possess the average facility in breathing, speaking and 
swallowing. Whatever may be the physiological function 
of this part of the palate, it cannot be of great importance 
and, in the present state of our knowledge, is a matter of 
conjecture. 

Uvulitis may appear as a primary disease, the other parts 
of the throat being unaffected, but it much more commonly 
arises secondarily in consequence of tonsillitis or pharyngitis, 
continuity of surface and similarity of structure greatly facili- 
tating the mutual extension of morbid action from organ to 
organ. The symptoms vary much in different patients, 
because some persons can tolerate an enlarged uvula with 
nothing more -than occasional discomfort, while the sensitive- 
ness of others brings on nausea and even vomiting, particularly 
in the morning, together with a persistent cough. This 
cough has in many instances given rise to a dread of tuber- 
culosis of which it is hard to disabuse the patient's mind by 
assurances that no lung disease is present. Under such cir- 
cumstances, active measures should be employed to effect a 
prompt cure, or the sufferer is apt to fall into the hands of a 
charlatan who will foment his fears, while they prove profit- 
able, and, when the patient grows restive, will shorten the 
uvula and thus effect a "wonderful cure of advanced con- 
sumption, in the very nick of time." In uvulitis visual ex- 
amination shows the organ to be elongated, swollen, cedema- 
tous and bright red in color, the distended wall exhibiting a 
glazed surface with patches that appear semi-translucent. 
It may be long enough to touch the larynx and large enough 
to obstruct the breath-road very seriously, even to the point 
of suffocation. 

The treatment of mild cases, where the inflammation is 
recent and nonseptic, need comprise nothing beyond the 
evacuation of the accumulated serum and constriction of 
the uvular pouch, to prevent recurrence of the engorgement. 
After irrigating the throat with Dobell's solution, or a similar 



200 NOSE, THROAT AND EAR 

alkaline wash, a straight, sharp-pointed bistoury should be 
used to scarify the distended sack. Four or five punctures 
should be made very quickly, then the head should be bent 
forward and the escaping serum drained away by gravity, 
or ejected by expectoration. A few small holes are sufficient 
for the escape of the contents which are entirely liquid, and 
these minute punctures, closing at once by contraction of 
the mucosa, are better than larger incisions, admitting the air 
with the possibility of inducing suppuration. After the 
serum has escaped, the collapsed, shriveled membrane should 
be painted with an eight per cent, solution of tannic acid 
in glycerine which acts not only by the astringency of the 
tannin, but by the hydroscopic property of the glycerine 
that takes up any water which may exude from the interior 
of the sack. This application can be used daily and, in the 
intervals, a spray of solution of epinephrin chloride whose 
strength is one to ten thousand. These measures often prove 
curative for simple catarrhal uvulitis, in the course of six or 
seven days. 

Chronic uvulitis, with elongation, presupposes such length- 
ened continuance of the morbid state, that the distended wall 
has lost its elasticity and, although scarification may render 
it flabby, there is little shortening effected by either the knife 
or astringents, and there remains a vermiform membrane, 
pendulous and flaccid, lying upon the tongue, or oscillating 
in the laryngo-pharynx and provoking cough, nausea, per- 
haps pharyngalgia. When this condition is established, the 
lower segment of the uvula acts as a mechanical irritant, 
much as if it were a foreign body suspended and motile, hence 
very little can be accomplished with pharmaceutical remedies : 
the irritation will continue, as long as the irritating body 
remains, therefore, the superfluous part of the uvula, the ab- 
normally elongated segment, must be amputated. 

For this operation the patient should, as always, be care- 
fully prepared, the surgeon making sure that there is no valid 
counter-indication to the procedure contemplated; then the 



THE UVULA 201 

throat is cleansed and local anaesthesia induced by painting 
the operative field with an eight per cent, solution of cocaine 
applied by a cotton-tipped carrier. As the anaesthesia is 
local and the patient is fully conscious, it is best for him to 
sit erect in a chair having an adjustable head rest. 

This amputation involves at the start a choice 
of implements in accordance with the purpose 
to use one-handed or two-handed instrumenta- 
tion. 1 One of the best known single-hand de- 
vices is the uvula scissors of the late Dr. Carl 
Seiler. He invented them to meet the exigen- 
cies of the old-time dispensary service in which 
a surgeon had very little help from trained as- 
sistants. To keep the operator's left hand free, 
while the right hand performed the amputa- 
tion, was a leading purpose of Dr. Seiler. In 
describing the instrument he says: "The 
handles are curved so that the hand holding 
them is below the level of the patient's mouth 
(upright posture) ; the right blade is bent at a 
ninety-degree angle, so there is a hook near its 
end; the left blade is straight and extends to 
the upper margin of the right blade where it 
is bent. When the blades are separated a tri- er's uvula scissors. 
angle is formed through which the uvula drops ^dbul^can 
and is severed near its base when the blades be performed by 
come together. It is prevented from slipping on i y . 
backward out of grasp by the hook-like bend 
of the right blade. The amputated piece is caught by a pair of 
pronged claws attached to the pivot on the under surface of the 
instrument." The inventor who had remarkable talent as a 
mechanician thought highly of this instrument and performed a 
large number of operations with the original model which was 

1 This is a choice presented in a number of operations and a surgeon's preference 
is influenced by personal considerations, largely by his dexterity with his left hand 
which seems like a pun, but is quite important. 




202 NOSE, THROAT AND EAR 

made under his close, personal supervision. In his opinion and 
in that of his co-workers this implement was almost perfectly 
adapted to the purpose in view. In our time surgeons cannot 
always secure by this operation the neat and well-finished re- 
sults described by Dr. Seiler and their disappointment may be 
due to the instruments used. Those upon sale in the shops 
differ among themselves, as is common with implements of 
complex construction, and a slight variation may affect opera- 
tive details. The instrument which we buy is not an exact 
duplicate of the model which satisfied Dr. Seller's very critical 




Fig. 72. — Shortening an elongated uvula; bimanual operation. 

judgment and with which he performed his operations. 
We cannot expect the results to be identical. Fig. 71 shows 
an instrument intended to combine the features described by 
Dr. Seiler. 

In a majority of cases I prefer the bimanual technique, 
employing grasping forceps and straight, blunt-pointed scissors. 
The preparation of the patient and the anaesthesia are those 
already described; then the tip of the uvula is seized with 
the forceps, enough tissue being taken between the blades to 
give a firm hold. With the forceps in the left hand, traction 
is made toward the front of the mouth, so as to put the uvula 



THE UVULA 203 

upon a stretch. The redundant portion below the muscles 
and blood vessels is amputated with scissors held by the 
right hand, the incision running from before backward and 
from below upward. This produces a beveled surface with 
the raw side at the rear and prevents food and drink im- 
pinging upon the wound. If unusual bleeding occurs it is 
checked by the eight per cent, solution of tannic acid in gly- 
cerine or a slight touch of the galvanocautery. Until healing 
takes place, the diet should be unstimulating and bland and 
care should be taken that nothing enters the mouth which 
could' exert a toxic influence upon the granulating surface. 
Fig. 72 depicts the bimanual procedure. 



CHAPTER XIX 
THE FAUCIAL TONSILS 

The faucial tonsils, situated in the trianguloid cavity 
between the pillars of the fauces, bear their descriptive name 
to distinguish them from the pharyngeal and lingual bodies 
of similar structure; but they are commonly termed simply 
the tonsils and when the name is used alone, the 'faucial ton- 
sils are always the ones intended. They are glandular bodies, 
in shape somewhat like an almond, a resemblance leading to 
the name amygdalae which they bear in several languages. 
The tonsils grow rapidly during childhood, reaching their 
full size at puberty or soon afterward, and at this period they 
are most susceptible to disease. In common with other lymph- 
oid structures they undergo atrophic changes after the body 
attains maturity, and in middle life they are generally small, 
fibrous and ischemic, showing little activity of any sort. 
This change does not occur in everyone. Some persons 
past fifty still have large, vascular tonsils subject to inflamma- 
tory attacks. The death of Washington was attributed by 
his physicians to acute tonsillitis or quinsy, the name by 
which the disease was then designated; but some critical his- 
torians doubt the accuracy of the medical report. 

In size the fully developed tonsil shows much variation in 
different individuals; the length of its greatest diameter, as 
given by anatomists, is from three-fourths of an inch to an 
inch; the weight including the capsule is from 90 to 120 grains. 
The largest measurements found upon record pertain to a pair 
of tonsils which I removed from a youth of nineteen years. 
The larger was two inches long and weighed 265 grains; the 
smaller was a little less than two inches in length with a weight 
of 217 grains. These extraordinary dimensions were due to 



THE FATJCIAL TONSILS 205 

hypertrophic enlargement, which had been progressing for 
years and had produced very distressing and dangerous 
symptoms. 

The tonsil consists of a cellular mass interlaced by fibers 
of connective tissue and liberally supplied with blood coming 
from ramifications of the lingual, facial, internal maxillary 
and external carotid arteries. Its body is enveloped by a 
fibrous capsule, which is incomplete on the side toward the 
uvula, where are found many orifices leading into the crypts or 
follicles distributed through the interior of the organ. These 
crypts are lined with mucous membrane whose normal secretion, 
here as elsewhere, is liquid and readily escapes from the orifices. 
In disease, however, it becomes thick and mingling with morbid 
products produces a caseous mass of a yellowish-gray color 
which fills the crypts and even spreads over the spaces between 
them. Lymphatics connecting with cervical glands bring the 
tonsil into association with the general lymph circulation. 

The physiology of the tonsils is undetermined. Many 
suggestions have been made: perhaps it has some prenatal 
function; perhaps it is a vestige of some obsolete organ; perhaps 
it modifies the secretions of the ductless glands carried in the 
blood plasma. These conjectures are offered because many 
believe that the existence of an organ necessarily implies a 
function for that organ. 1 As a matter of fact, we do not know 
whether the tonsil has a function; if there be one, it cannot be 
important, for there is no proof that deprivation of the tonsils 
has injurious consequences. Operative accidents may do 
harm but accidents are no impeachment of the operation 
itself. In the present state of our knowledge we cannot 
assert that any useful function is performed by this organ. 
When we consider negative physiology the phenomena asso- 

1 "in natura stat nihil inutile: quod adest, idem prodest." This old argument 
has influenced many minds and has stimulated an earnest search for functions, 
with good results. Admitting that the tonsil has a function, we have gained 
nothing, until we know what it is. If the organ were left in place we would be 
liable to do many things detrimental to a function of which we possessed no 
description. 



206 NOSE, THROAT AND EAR 

dated with an organ, which do not assist the action of other 
organs, do not promote the health of the whole body but 
induce disorder and favor disease; then the activity of the tonsils 
is beyond question. There is no doubt they are gateways for 
pathogenic germs carried by food, drink and air, which not only 
are the causative factors in the pathology of the throat affections, 
but also enter the blood vessels and lymphatics, migrate to 
distant parts of the body and originate nephritis, orchitis, 
adenitis and other maladies. The tonsillar crypts also serve as 
receptacles for procrastinating microbes of some of the infectious 
fevers, particularly diphtheria, so that a convalescent, who 
has no longer any symptoms of the disease, is still a carrier of 
contagion. The dormant germs may continue inactive for a 
long time and then suddenly manifest all their pristine virulence. 
The evil effects of tonsillar disease are either obstructive or 
toxic. Enlargement, from whatever cause, soon produces 
mechanical interference with the food-road, and secondarily 
with the breath-road. Even a moderate augmentation in the 
size of the organ serves to constrict the oropharyngeal orifice 
and gives rise to dysphagia; because the tonsil's anatomical 
situation is such that, when enlarged, its extension must be 
almost wholly in one direction, that is, toward the median line 
of the fauces and a swelling, which would appear moderate if 
concentrically distributed, is sufficient to encroach seriously 
upon the open space and, if both glands are affected, to close 
the passage. If the enlargement goes on after the food-road 
has been occluded, the tonsils are forced to bulge backward 
into the meso-pharynx and the passageway is further narrowed 
by the engorgement of the palatine and pharyngeal mucosa 
made cedematous by pressure. These changes obstruct the 
breath-road along its course from the posterior nares to the 
larynx and the obstruction is increased by the thick, mucous 
secretion often produced abundantly and which, on account 
of its peculiarly tenacious character, adheres to the surface in 
large patches nearly as thick as a pseudo-membrane. If the 
oedema extends to the larynx, death is imminent and trache- 



THE FAUCIAL TONSILS 207 

otomy is demanded. Aside from such complication fatalities 
are rare, but the embarrassment of respiration is great and very 
distressing to the patient. It should be promptly relieved and 
held in abeyance until the retrocession of the congestion 
relieves fear of further obstruction. To palliate this condition 
the tonsils should be freely scarified upon their anterior surface, 
the released blood serum (sometimes pus) running out over 
the tongue and being cleansed away from the mouth. The 
quantity of fluid which escapes is often surprising and the 
relief of the patient's distress is immediate. A single scarification 
is all that is usually required to obviate obstruction of the 
breath- road; but if much fluid again accumulates, it should be 
again evacuated. When the acute symptoms begin to decline 
urgent danger from respiratory obstruction is past; but we have 
to consider the effects of partial obstruction, together with 
other sequels of the recurrent and chronic morbid processes 
due to the action of toxins and, to some extent, of nontoxic 
irritants. The tonsil occupies an exposed position and its 
lacunae give easy entrance to germs carried into the oral cavity 
hence micro-organisms are found associated with all tonsillar 
diseases. Even in acute, catarrhal tonsillitis smears show the 
presence of microbes, often representing many species including, 
of course, those which are habitually found in the mouth. 
These are ordinarily harmless but it is probable that they act 
as irritants when the tonsils are in a state of abnormal sus- 
ceptibility, a condition produced by sudden changes in tem- 
perature and barometric pressure, whose effect upon the 
pharynx was discussed in Chapter XVII. The opinion that 
these nontoxic germs may irritate supersusceptible tissues is sup- 
ported by the fact that tonsillitis may at its start be aborted 
by making an impervious coating of coagulated albumen 
upon the mucous membrane with a strong solution of silver 
nitrate applied on the convex surface of the gland, so as to 
coagulate the albumen of the mucosa and form an impervious 
coating sealing up the lacunae for several days. The rational 
explanation appears to be that the caustic destroys the germs 



208 NOSE, THROAT AND EAR 

which have already entered the epithelial layer and the coating 
prevents any others gaining access for the time being, until 
the special susceptibility has passed away after which they 
do no harm. 

Acute tonsillitis is remarkable for the severity of its symp- 
toms when compared with many diseases involving greater 
danger. Its mortality is almost nil but it may have injurious 
sequelae and should not be regarded as trivial. It is usually 
ushered in by a chill followed by rapid rise of temperature, 
which generally reaches 103 and may go to 105 F. There is 
headache and backache with pain in the throat and as the 
swelling increases those signs of obstruction to the food- and 
breath-roads which have been already described. Albuminuria 
has been mentioned by some authors as an incident of the 
disease but it often signifies the onset of intercurrent 
nephritis caused by infections conveyed from the tonsil. The 
blood pressure should be taken whenever albumen appears 
in the urine and, if there be a rise of twenty millimeters 
or more above the average, it is a signal of the gravest import 
and a mandate to promptly antagonize the developing renal 
disease. At the beginning of an attack of tonsillitis, as of 
other febrile affections, the patient should be put to bed in a 
quiet room and the alimentary canal should be emptied by a 
mercurial cathartic followed, if needful, by a saline. A 
bowl of broken ice should be within the patient's reach and 
fragments kept in the mouth; a. simple expedient which does 
a great deal to assuage thirst and lessen discomfort. Medica- 
tion by the stomach is possible only before deglutition is 
interrupted by the swelling, or after its restoration, following 
scarification. This is true also in regard to feeding. During 
the severe stage little food is required; milk or broth with 
free drinking of water proves sufficient while the fever is 
at its height. The tincture of guaiac in doses of a fluidram, 
mixed with milk, should be given at intervals of six hours, for 
its alterative effect. The pyrexia is well controlled by tincture 
of aconite root, Tfl,x (dose for an adult), repeated every fourth 



THE FAUCIAL TONSILS 2O0 

hour, until the pulse becomes slower and less resilient. Pain 
and restlessness are nearly always alleviated by a hypodermic 
injection of one-fourth grain morphias sulphate and 34s o grain 
atropiae sulphate (adult dose), which also relieves the embarrass- 
ment of the respiration. Cold upon the outside of the throat, 
the "ice-bag cravat," may modify the course of disease, if ap- 
plied before the formation of pus, while resolution is still pos- 
sible. It is counter-indicated by suppuration. Washes of 
any kind are impracticable because of the turgescent and pain- 
ful conditions, but advantage is derived from spraying the 
palate and tonsils with the usual three per cent, solution of 
hydrogen peroxide diluted with an equal quantity of water. 
This serves to detach and dissolve the tough, tenacious secre- 
tions adhering to the mucous membrane. A mixture of 
equal parts of tincture of iron chloride and glycerine applied 
to the tonsil with a cotton-tipped probe proves useful in some 
cases by its antiseptic and astringent properties. When 
pus forms it must, here as elsewhere, be given a free outlet. 

Phlegmonous tonsillitis, peritonsillar abscess or quinsy, 
is a variety characterized by rapid and profuse suppura- 
tion, which usually infiltrates the soft palate and sometimes ex- 
tends to the retro-pharynx. It is nearly always unilateral. 
The predominant indication in this type of the disease is to 
thoroughly evacuate the incarcerated pus. As soon as its 
presence is signified by fluctuation or other tokens an in- 
cision should be made at the spot where the abscess points, if 
this spot can be found; even if it cannot, there should be no 
procrastination, but the pus cavity should be penetrated at 
some place on the front surface. There is danger in delay, 
for the abscess may "point" posteriorly into the pharynx, 
which the swelling entirely hides from our view, and while 
we wait there may be a spontaneous rupture, discharging the 
entire accumulation into the larynx. This deplorable acci- 
dent has occurred several times and is responsible for nearly 
all the fatalities reported in quinsy. In this variety the 
constitutional and topical treatment is similar to that 
14 



2IO NOSE, THROAT AND EAR 

advised in the catarrhal, nonsuppurative type. The rheu- 
matic diathesis predisposes to attacks of quinsy which, 
instead of protecting the patient against recurrence, really 
increase his susceptibility. During the intervals the sali- 
cylates or their derivatives should be administered, com- 
bined with alkalies, if the urine shows abnormal acidity. 
This treatment tends to postpone the occurrence of subse- 
quent attacks and to render them less severe but is, after 
all, only a temporary expedient till the patient consents to 
a radical cure by the removal of the nosogenic organs. 

As observed upon a previous page the injurious effects of 
tonsillar disease are either obstructive or toxic. Several 
varieties in which the second factor is prominent are now to 
be considered. 

Follicular or lacunar tonsillitis (Fig. 73) is a form of the 
disease in which the crypts are chiefly affected. It is caused 
by pathogenic germs, especially the streptococcus, staphylo- 
coccus and pneumococcus. These invade the crypts and so 
affect the surrounding tissues that the spaces become clogged 
with devitalized epithelium, leukocytes and necrotic detritus 
of various kinds. The engorged crypts appear upon the 
tonsillar surface as dirty yellow spots, a characteristic sign, 
and a yellow secretion exuding from some that are over- 
full dries upon the surface and looks like fibrous bands. Some- 
times the degenerating material is so abundant as to form 
upon part of the cortex a coating which somewhat resembles a 
pseudo-membrane but lacks its consistence, toughness and pecu- 
liar gray color. The subjective symptoms resemble those of 
the catarrhal form but are less acute. Metastatic infections of 
the Eustachian tube, middle ear, joints and cervical glands 
are sequels which occur not infrequently. 

Treatment includes the constitutional measures of an 
antifebrile kind advised when speaking of the catarrhal form 
with such additions as special symptoms may require. Effi- 
cient action of the bowels should be maintained by giving 
calomel in small and frequent doses. Headache and mus- 




Fig. 73. — Follicular or lacunar tonsillitis. 



(Facing page 210.) 



THE FAUCIAL TONSILS 211 

cular and joint pains can be mitigated by administering at 
two-hour intervals a powder containing: Acetanilid, gr. ij. 
and Acetyl-salicylic acid gr. v. Occasionally a small hy- 
podermic injection of morphia may be necessary. The local 
exudate should be dislodged by the peroxide of hydrogen so- 
lution and the cleansed surface painted with equal parts of 
guaiacol and petrolatum liquidum, twice daily. Crypts which 
do not become normal under this treatment should be cau- 
terized with solution of silver nitrate, 5 j to fl. § j. 

Ulcerative tonsillitis, or Vincent's angina (Fig. 74) is differ- 
entiated from other varieties by its etiology. The disease is 
always caused by two germs, a fusiform bacillus and a spirillum 
forming a network over it. Both microbes were isolated by 
Vincent and bear his name. The symptoms are the same as 
those shown by other forms. The upper surface of the tonsil is 
first affected and the lower part may remain normal. The 
lesions are patches of gray film, due to necrosis of the mucosa 
caused by the invading germs and these patches have areolas 
of red, congested membrane. When the films are lifted, an 
ulcer is disclosed. This, if left to itself, may be again covered 
with a pseudo-membrane, or may extend into the surrounding 
healthy tissue and grow deeper by erosion at its base. As a 
germicide, tincture of iodine should be applied directly to the 
surface of the ulcers. It may be used daily and, after an 
interval of several hours, be followed by the application in the 
same way of an eight per cent, solution of silver nitrate. These 
remedies, employed with thoroughness, will destroy the germs, 
after which recovery will take place without further topical 
treatment. Constitutional conditions should receive attention 
as in other tonsillar inflammations. 

Mycosis leptothrica is a morbid condition affecting the crypts 
and follicles of the faucial tonsils and liable to extend to the 
lingual tonsil and other lymphoid structures of the throat. It 
is caused by a fungus, called the leptothrix buccalis, which is 
common in the tartar upon the teeth and is thought to bear a 
causal relation to dental caries. This vegetation, while: 



212 NOSE, THROAT AND EAR 

showing little pathogenic power in its common oral habitat, 
has been discovered in association with diseases of very malign 
character; it has been found in the faeces during typhus fever 
and in the necrotic tissues of pulmonary gangrene. Perhaps 
its presence in such situations is accidental. Upon the mucous 
membrane it appears in clumps of rods or tufts of a white or 
yellowish color, distinctly raised above the epithelium and 
projecting abundantly from the crypts of the faucial tonsils, 
also frequently growing plentifully from the follicles of the 
lingual tonsil and other lymphoid bodies. This fungus is often 
present in the mouths of persons whose throats show no sign 
of its presence and it does not invade the fauces of those using 
tobacco, either as chewers or smokers. This curious fact 
probably explains why its tonsillar manifestations are much 
more common among females than males. 

After a crypt has been occupied by the leptothrix for some 
time we find in its center a mass of horn-like tissue due to 
metamorphosis of the epithelium under influence of the fungus. 
From this hard, dense substance, the disease derives its alter- 
native name tonsillar hyperkeratosis. This mass may take a 
conical shape with the apex protruding from the crypt and 
making indentations or abrasions upon softer tissues with 
which it is brought in contact. Inside the crypt the lepto- 
thrix is found in active growth and, together with it, other 
species of micro-organisms, often numerous and diversified, 
which find in the lacunae conditions most favorable to their 
multiplication. The surrounding walls show remains of the 
epithelial cells which have nourished the bacteria and great 
numbers of which have been destroyed, while a few of unusual 
resistent power continue in a nearly normal state, in the midst 
of the necrotic detritus. 

The patient may be made conscious of the existence of this 
horny mass, impinging upon adjacent structures, by the friction 
and abrasions above mentioned, which give rise to a pricking or 
tickling sensation; but, aside from such sensory impressions, 
the disease rarely causes any symptoms and its presence is 






Fig. 74.— Ulcerative tonsillitis; Vincent's angim 



(Facing page 212.) 



THE PAUCIAL TONSILS - 213 

usually discovered during an inspection of the throat under- 
taken for some different purpose. This affection belongs to the 
period between puberty and fully developed maturity, being 
rarely seen after the twenty-fifth year. Commonly it is self- 
limited, running a course of two or three years and then dis- 
appearing spontaneously. 

Treatment of a constitutional kind has no apparent effect 
upon mycosis and the only local measures which accomplish 
anything are germicidal applications, which destroy the fungus 
and its products. For this purpose the chemical caustics have 
been used and also the galvanic cautery. The plan I prefer is 
to render the tonsil insensible with cocaine and then to remove 
from the crypt decayed epithelium and all other detritus with 
a Buck dull ear curette afterward painting the partly emptied 
cavity with the iodine solution, No. 2, mentioned in Chapter 
VII (R/,. Iodini, gr. xij, Potas. iodidi, gr. xxxvj, Glycerini, 
fl. 3 viss. M.) and repeating the application daily, or upon 
alternate days, until the surface of the cavity begins to show a 
normal appearance; afterward at longer intervals. Under the 
influence of this powerful germicide and alterative, the less 
dense morbid growths disintegrate and, though the keratoid 
core of the mass in the crypt may resist the solvent action, it 
is loosened from the surrounding tissues and may often be 
readily dislodged with forceps. After its removal and the 
elimination of all degenerating structural elements from the 
interior of the crypt, the denuded surfaces are kept clean and 
encouraged to heal by granulation. 

If only one or two of the lacunae have been invaded by the 
fungus, this treatment may prove satisfactory and the cure 
may be permanent, but when the leptothrix has affected a large 
number of the crypts, the method described is open to several 
objections. The curettement and first iodinization are too 
painful to be done without anaesthesia and they consume so 
much time that only one or two crypts can be dealt with at a 
single sitting, hence the patient must undergo a series of opera- 
tions, each one involving local anaesthesia, each one requiring 



214 NOSE, THROAT AND EAR 

considerable time for the healing process. Such a series of 
surgical procedures requires an amount of patience and persever- 
ance which many patients lack; they are apt to become dis- 
couraged and abandon treatment — a result unfortunate for 
both patient and physician. It is, therefore, best in multi- 
cryptic cases to advise the extirpation of the fungus in one or 
two lacunae, where it is giving most trouble, but to present this 
as simply a palliative measure, preliminary to the radical and 
rational operation which effects a complete cure and makes 
recurrence impossible, viz.: the enucleation of the tonsil to- 
gether with its capsule to be described in following pages. 

Diphtheria (Fig. 75) is preeminent among the diseases 
whose tonsillar manifestations are serious on account of 
toxicity rather than obstruction (see former pages of this 
chapter) . Obstruction does play a part in the clinical history, 
but its stage is the larynx rather than the fauces. Although 
a constitutional disease affecting the entire organism, diph- 
theria exhibits topical phenomena chiefly in the throat and 
nose and its germs are found in great abundance in these 
localities, while only sparsely in the blood and visceral organs. 
In considering the nasal form of the malady (Chapter VIII) , 
its etiology and its treatment by antitoxin were discussed. 
Here it is only necessary to mention certain features which 
characterize its tonsillar manifestations. Of these the most 
conspicuous is that from which the disease derives its name 
(8i<t>d*pa = membrane). This false membrane, of a dirty 
gray color and peculiar, repulsive odor, is found covering the 
cortex of the tonsils in nearly all cases where the pathogenic 
bacillus finds lodgement in the throat. It may spread to the 
soft palate, to the walls of the pharynx, and through the oral 
cavity; but the tonsils are nearly always the first structures 
affected. As this lesion can be seen at the beginning of the 
attack, it is a most important factor in making the diagnosis. 
There is only one disease 1 with which diphtheria is likely to 

1 1 do not think scarlet fever raises a diagnostic difficulty. The absence of 
the false membrane and the presence of the strawberry tongue, scarlet eruption 
and very high temperature, are sufficient to identify it. 




Fig. 75.— Diphtheria; patches of pseudomembrane on the tonsils and uvula. 



(Facing page 214.) 



THE FAUCIAL TONSILS 215 

be confused, that is follicular tonsillitis. The thick substance 
exuding from the overfilled follicles and spreading over the 
intervening spaces of the mucosa forms a coating which 
bears a resemblance to the pseudo-membrane. These similar 
manifestations can nearly always be differentiated by the 
following distinctive features, some of which are almost sure 
to be present. 

Diphtheritic false membrane Exudate of follicular tonsillitis 

Spreads from tonsils to soft palate and Confined to cortex of tonsils. 

elsewhere. 

Color, a peculiar dirty gray. Color, yellowish gray with streaks. 

Tough and resistant; frayed edges. Pulpy and easily broken. 

Raw, bleeding surface left by removal. Removal leaves red mucosa. 

Peculiar, necrotic odor. Odor slight or absent. 

The cases are rare where an experienced physician, giving 
careful attention to these signs, proves unable to make a 
correct diagnosis; but if, after all details have been con- 
sidered, there is still doubt as to the nature of the disease, then 
this doubt should be resolved by a bacteriological test. The 
finding of the Klebs-Loeffler bacillus in a smear taken from 
the tonsil will, of course, determine the question. When the 
constitutional symptoms are pronounced, prudence dictates 
that the serum treatment should not be held in abeyance 
while we wait for a laboratory report regarding the germs. 
It is better to administer a dose of antitoxin to a patient very 
ill with a form of tonsillitis, than to incur the risk of with- 
holding it from what may prove to be a fulminating case of 
diphtheria. 

Local treatment is useful in lessening the inflammation of 
the mucous membrane and ameliorating the patient's suffer- 
ings while the toxins are being eliminated. The nose and 
throat may be irrigated four or five times a day by employing 
a soft catheter attached to a fountain syringe or a rubber- 
bulb syringe of large capacity. Liquids thus used should 
be warm and should be very slowly injected. Among those 
well suited for the purpose are the normal salt solution and 



2l6 NOSE, THROAT AND EAR 

a saturated solution of boric acid. The common three per 
cent, solution of hydrogen peroxide, diluted with thrice its 
bulk of lime water, may, when the mouth can be readily 
opened, be applied to the fauces with a swab. In a similar 
way use may be made of the following antiseptic and as- 
tringent mixture: 

1$. Mentholis oiiss 

Toluolis fl. ox 

Alcoholis absoluti fl. 5ij 

Liquoris ferri chloridi fl. 5 j- M. 

Chronic tonsillitis (Fig. 76) to which the names hyper- 
trophic and hyperplastic also are applied is generally due to 
a succession of acute attacks, each one adding something to 
the deposit of products of inflammation and increasing the 
amount of connective tissue by which the normal cells of 
the organ have been superseded. By repeated distention 
the walls of the blood vessels lose their elasticity and their 
engorgement becomes permanent. The symptoms are those 
of chronic irritation. The patient has a "weak throat" and 
is never entirely well; he has always some faucial discomfort, 
always a liability to attacks of intercurrent diseases of a 
digestive, articular or nervous kind. When the morbid con- 
dition has lasted for a long time the tonsil may be brought to 
such an unhealthy state as to act the part of an obstructive 
foreign body. It is hypertrophied, engorged, indurated, 
germ-infested, so damaged by disease as to be little more 
than a mass of morbid tissue that is good for nothing and 
is a constant menace to the health of the organism. There 
are many stages between moderate tonsillar hypertrophy and 
this final detrimental state, and the trend of medical thought 
is to resort to the radical processes of surgery, at an early 
stage, rather than to allow the patient to suffer many acute 
attacks, waste much time and perhaps implant disease in 
other organs. 

Three operations have been devised for the treatment 
of chronically enlarged tonsils. The first is the obliteration 




Fjg. 76. — Chronic or hypertrophic tonsillitis. The tonsils here portrayed are 
those mentioned at the beginning of Chapter XIX, as the largest on record. 



(Facing page 216.) 



THE FAUCIAL TONSILS 21.7 

of the crypts, the particular purpose in view being the pre- 
vention of the entrance and dissemination of pathogenic germs. 
This procedure requires that each cavity shall be laid open 
and its inner surface be denuded, either by a specially de- 
vised knife or by the galvanocautery, so that the reparative 
process will efface the crypt. To reach all the crypts numerous 
operations are required and, while they certainly do fulfil 
their purpose by closing the gateway for infections, they are 
attended with serious disadvantages. They are painful 
and tedious, extending over many weeks, and patients are 
liable to become discouraged and to abandon treatment. 
Then, too, we cannot be certain that we have found all the 
crypts and immunity from infection is not attained until 
every one is obliterated. The value of the procedure seems to 
be • limited to those persons who are affected by haemophilia 
in whom all incisions however slight are attended by danger. 

The second operation is tonsillotomy, the amputation of 
a segment of the gland including the cortex and more or less 
of the adjoining tissue. This was at one time a very popular 
procedure and it relieved many of the symptoms of an ob- 
structive kind, which caused the patient much annoyance. 
It had, however, many drawbacks. The segment left by the 
amputation often became hypertrophied, protruded beyond 
the f aucial pillars and brought back the old troubles, necessitat- 
ing a second operation. Often the irritability of the fauces 
was but partially alleviated, the patient still had a "weak 
throat" and was still subject to recurrent attacks of acute 
inflammation. Besides all this, tonsillotomy proved a failure 
as a means of preventing infection. Crypts still existed in 
the remaining segment and in the capsule, furnishing breeding 
grounds for many varieties of bacteria, ever ready to migrate 
inward and to spread contagion throughout the organism. 

For these reasons tonsillotomy has to a great degree been 
superseded by the more radical tonsillectomy and in many 
parts of the country is now seldom performed. There are 
localities where this operation is still frequent and is done by 



2l8 NOSE, THROAT AND EAR 

nonspecialists, who consider it as included in general medical 
practice. This is a most mistaken view. If tonsillotomy is 
done at all, it should be done by one fitted for the task by 
training and experience. I know very well that, when a 
specialist makes such a remark, many think he is actuated by 
motives of self interest but the truth must be told in spite of 
sarcastic smiles and shoulder shrugs. It is not only because he 
is liable to wound the contiguous structures that the un- 
trained, inexperienced physician should not attempt an opera- 
tion of this kind; there is a graver danger; unwittingly he im- 
perils the patient's life. The risk of serious haemorrhage is 
always present in tonsillar amputation. This risk has been 
strangely minimized in our literature, perhaps because the 
authors thought their readers knew the facts anyway. Some 
text books make only a perfunctory remark like this: "After 
the operation any tendency to haemorrhage should receive 
proper attention." The untrained man who reads such a 
statement naturally concludes that the danger is slight. It 
may be very grave. In general practice one encounters 
chiefly uterine haemorrhage, pulmonary haemorrhage and 
the bleeding from wounds of the upper and lower extremities 
caused by axes, saws and other tools. The arrest of such 
bleeding does not qualify one to treat a faucial haemorrhage 
where the anatomical conditions are wholly different; and 
yet no one should operate in this region unless he knows how 
to prevent and how to arrest such a haemorrhage. Fatalities 
due to this cause may be but seldom reported in the journals, 
but they are by no means rare. 

The foregoing discussion leads up to the consideration of the 
operation, which in my opinion is the solution of the tonsillar 
problem; the operation of tonsillectomy, the extirpation, or 
entire removal of the organ. What remains to be said, will 
be told in answer to the questions when, why, and how. It 
can be said that the tonsils should be removed when they 
become troublesome. Repeated attacks of acute tonsillitis, 
recurring at short intervals, signify that the patient is very 



THE TATJCTAL TONSILS 



219 



susceptible and they presage a long series of illnesses, handi- 
capping the youth in his educational course and the man in his 
vocation, with the addition of an undetermined danger of dis- 
ability or even fatal complications. These things constitute 
a cogent argument, which is much stronger if chronic disease 
be already present. The date of the operation should be se- 
lected in the interval between acute attacks; the menstrual 




IT. 



Schema showing arrangements for enucleating the right tonsil. 

O.T. operating table, upon which the patient lies in the dorsal posture, with 
head at H. 

S. station of surgeon. 

I.T. instrument table at surgeon's side. 

iV.station of nurse or assistant. 

A. station of anaesthetist. 

A.N.T. table for use of nurse and of anaesthetist; it bears the generator of 
ether vapor, gauze, etc. 

period is to be avoided, also occasions of mental or physical 
stress such as school examinations and athletic contests. The 
digestion and other functions should be normalized, as far as 
possible, preparatory to the operation so that the patient may 
have the best chance to make a prompt and complete recovery. 
Why do we resort to tonsillectomy? Because it is a cure, 
and the only trustworthy cure, for morbid conditions pregnant 
with possibilities of evil and because, when performed by a 
competent specialist, it neither endangers life nor inflicts 



2 20 NOSE, THROAT AND EAR 

permanent injur}- upon any organ or any function. That 
haemophilia and a few other contraindications exist, does not 
invalidate this assertion because an educated specialist would 
at once exclude such cases as inoperable. It is curious that 
some eminent laryngologists have manifested a prejudice against 
this operation which was all the stronger because it rested on 
sentimental, rather than scientific grounds. They would con- 
sent to mangling the crypts, or to cutting away the cortex, but 
enucleation, total removal of an organ, which is Mother Na- 
ture's handiwork; that seemed to them almost immoral ! When 
a noted London surgeon spoke of the "massacre of the tonsils," 
he strove to prejudge the question by using a term which always 
implies condemnation. Other authors have written in the 
same strain, but sentimental considerations cannot induce the 
clinical surgeon to spare a mass of diseased tissue which is both 
useless and dangerous. We kill the venomous cobra whenever 
we can. despite the teachings of Hindoo philosophy that 
the snake may harbor the soul of a Rajah. 

The final inquiry is how tonsillectomy shall be performed. 
In so far as the answer relates to the surgeon, it is positive and 
permits no exception. He must be a well-taught, well-trained, 
experienced specialist; the operation makes such demands upon 
both knowledge and skill that no one but an expert should under- 
take it; nor does it come within the category of those emer- 
gencies in which a physician is justified in attempting unfamiliar 
work because the patient's life depends upon immediate action. 
In this case the urgency is never so great as to prevent the en- 
gagement of a specialist. 

There are several methods of tonsillectomy: it is sufficient 
to describe two. The first is the craft-master's operation, using 
the simplest instruments and the aid of but two persons, an 
anaesthetist and a nurse, or other capable assistant. Their 
stations and the arrangement of the necessary furniture are 
shown in the schema upon page 219. The positions designated 
in the following description are those proper in removing the 
right tonsil; enucleation of the left requires their reversal. 



THE FAUCIAL TONSILS 



221 



The instruments adapted to this operation are depicted in 
Fig. 77. 




Fig. 77. — Instruments used in tonsillectomy. A, Tongue depressor; B, 
Denhart's mouth gag; C, Seiler's septum knife; D, Tonsil haemostatic forceps; 
E, Tonsil-seizing forceps; F, Smith's tonsil snare; G, Tonsil punch. 

The patient, having been physiologically prepared for the 
operation, is placed in the dorsal posture upon a table, pro- 



2 22 NOSE, THROAT AND EAR 

vided with an adjustable head piece, and is covered from the 
neck downward with a sterile sheet, the hair of the scalp being 
enveloped in a sterile rubber cap. The surgeon's station is on 
the left of the patient and within easy reach is his instrument 
table. The nurse stands on the patient's right side and the 
anaesthetist at his head; conveniently near to both is a small 
table bearing the ether bottle, inhaler, picked gauze and the gen- 
erator of ether vapor used to prolong the anaesthesia. Good 
illumination is indispensable. Every part of the field of opera- 
tion should be clearly visible so that every manipulation may 
be distinctly seen. The acromatic and other advantages of 
sunlight are counterbalanced by the difficulty in securing direct 
radiation, the risk of cloudy weather and other drawbacks; so 
we are forced to rely upon artificial illuminants, among which 
I prefer Hodson's electric headlight. After anaesthesia has 
been induced by the inhalation of ether, the head piece of the 
operating table is let down, so that the patient's pharynx is on 
a lower level than the glottis, in order that escaping blood may 
gravitate toward the naso-pharynx, not toward the trachea. It 
is the assistant's duty to dexterously remove such blood with 
mops of picked gauze. A mouth gag (Denhart's is good) is 
then inserted and the ether vapor tube introduced at the right 
corner of the mouth. The tongue depressor is employed to hold 
the tongue away from the right side of the faucial arch, bringing 
the tonsil into plain view. 

This is the close of the preparatory stage, and before entering 
upon the next phase, the surgeon reviews the environment and 
all the conditions, the state of the patient and attitude of the 
assistants. This inspection may take only a moment or two; 
but it is highly important and the surgeon should be assured 
that everything is right before he takes the next step. 

This step is to seize the tonsil and drag it out of its fossa. 
For this a good instrument is needed. The diseased organ is 
often indurated, occasionally pultaceous; in the former case a 
clutching implement is apt to slip off, in the latter to tear its 
way out. To secure an instrument not liable to either mishap, 



THE FAUCIAL TONSILS 223 

I have devised a strongly made, long forceps which is straight, 
except for a downward curve in the handles. Each blade has a 
small fenestra and its inner surface is serrated, so that the alter- 
nate ridges and grooves fit the grooves and ridges of the com- 
panion blade. I have rarely seen these blades slip off or tear 
out. With such an instrument the tonsil is firmly grasped and 




First stage in operation of tonsillectomy. 



traction made in a line diagonally across the mouth with suf- 
ficient force to bring the body out of its fossa and to expose 
its hidden outlines. While the left hand holds the forceps, the 
surgeon with his right hand inserts the blade of a Seiler septum 
knife as close as possible to the tongue, between the tonsil and 
the anterior pillar of the fauces, keeping the concave surface of 
the blade in contact with the tonsil. If necessary, the incision 
is carried through the plica triangularis and is then continued 



2 24 



NOSE, THROAT AND EAR 



upward, keeping the blade behind the tonsil, until the supra- 
tonsillar lobe is dissected free from the fossa (Fig. 78). At this 
point the knife is turned, making nearly half of a complete ro- 
tation, and then cuts downward, separating the tonsil from the 
posterior pillar of the fauces and continuing the dissection down 
to the glossal margin (Fig. 79). The tongue depressor is now 




Fig. 79. — Second stage in operation of tonsillectomy. 



withdrawn and the right index-finger is introduced into the 
supratonsillar fossa. Keeping the finger between the tonsillar 
capsule and the wall of the fossa, with care not to injure the sur- 
rounding musculature, any fibers, which have not been cut, are 
digitally severed, being broken one by one and from above down- 
ward. By this process the tonsil should be entirely freed from 
attachments to the pillars and to the supratonsillar fossa. 
When such separation has been accomplished, but not till then, 



THE FAUCIAL TONSILS 



225 



the wire loop of a tonsillar snare is slipped over the handles of 
the forceps, still in place, and this loop is carefully.adjusted to 
encircle the base of the tonsil where there are still unsevered 
attachments (Fig. 80) . After the loop has been made snug, it 
is carefully examined at every point to make sure that it in- 
cludes no part of the faucial pillars or of the uvula. The wire 




Fig. 80. — Employment of the cold wire snare to complete the enucleation of the 
tonsil. 



is slowly tightened, gradually cutting through the tissues still 
holding the tonsil and, when they have been entirely dissevered, 
the surgeon withdraws the forceps, at the same time bringing 
away the enucleated mass. Fig. 81 shows the appearance of the 
fauces after removal of the tonsil. Immediately following this 
procedure, a pledget of picked gauze wrung out of an eight per 
cent, solution of tannic acid in glycerine is carried by a long 
curved hscmostat into the tonsillar fossa and packed there. 
is 



226 NOSE, THROAT AND EAR 

This will stop all capillary oozing and, if any bleeding still per- 
sists, search must be made for the bleeding point and this when 
found must be ligated. To facilitate finding a bleeding vessel 
Wood's pillar retractor is useful, though I prefer a delicate 
double tenaculum with which the anterior pillar is grasped at 
the junction of its upper and middle third. When the spot is 




Fig. 8i. — Appearance of the fauces after removal of the right tonsil. 

found, it is caught up by a long curved haemostat and encircled 
by a ligature. An even better plan is to use a small curved 
needle threaded with catgut of medium size. With this the 
thread is carried through the adjacent musculature and is tied 
so as to include the bleeding vessel. After the ligature has been 
made secure, the ends are cut and the hasmostat removed. 

When the surgeon feels assured that there is no danger from 
haemorrhage, the packing is finally taken out and the fossa care- 
fully scrutinized to ascertain whether any shreds of the ablated 
organ remain; if such are discovered they are at once removed 



THE FAUCIAL TONSILS 



227 



with biting forceps. General anaesthesia is best in this operation 
but under exceptional circumstances it may be performed by 
the local application of epinephrin chloride and cocaine, de- 
scribed fully in connection with 
intranasal operations. 

The other method of tonsil- 
lectomy which employs the ton- 
sillotome always requires general 
anaesthesia as local analgesia is 
not adapted to its technique. 
Mathieu's tonsillotome is a steel 
instrument about eight inches 
long of somewhat complicated 
construction. Its inventor in- 
tended it for tonsillotomy, but 
it can be utilized for the more 
radical and satisfactory opera- 
tion by following the technique 
hereafter detailed. It is shown 
in Fig. 8 2 . The mechanism com- 
prises three main portions, the 
other parts being mechanical 
devices for transmitting motion. 
First is the loop designed to 
engage the tonsil; it is a nearly 
circular, hollow oval, whose di- 
ameter is an inch or more. The 
second is the ring-shaped knife 
interposed in the loop, sharp on 
its inner circumference and cut- 
ting by traction toward the oper- 
ator. The third is a fork with 
two barbed prongs, which trans- 
fix the cortex of the organ and keep it from falling when cut 
off. To these I have added a fourth feature consisting of a 
chain with one end riveted close to the loop and the other end 




Fig. 82. — Mathieu's tonsillotome; 
upon one side is the transfixing fork, 
upon the other the chain and cross- 
piece. 



2 28 NOSE, THROAT AXD EAR 

terminating in an interdigital crosspiece. Traction on this with 
the surgeon's left hand causes the loop to encircle the tonsil well 
back from the cortex, avoiding the very common defect of en- 
gaging the gland in a shallow, superficial way so that the ring 
knife pares off only a thin slice. It is necessary, on account 
of variation in the size of diseased tonsils, to have three of the 
Mathieu instruments so that one may be used whose loop will 
just slip over the mass where its circumference is greatest. 

In enucleating the right tonsil, the stations of the surgeon and 
his assistants are those shown in the schema upon a former page. 
The physiological preparation, induction of anaesthesia, lowering 
of the head and illumination of the throat, are the same as those 
described in discussing the first method of operating. The 
differing technique begins by grasping the tonsillotome with 
the right hand, the first and second fingers passing through 
the lateral rings and the thumb through the ring on the fork. 
At the same time the crosspiece of the chain is grasped by the 
left hand. The instrument is passed through the mouth 
obliquely till the distal side of the loop is behind the tonsil in 
contact with the posterior faucial pillar and the shaft emerges 
near the left corner; then by traction on the chain combined 
with oscillation of the shaft the tonsil is brought fairly into the 
loop and, by further traction on the chain, is dragged forward 
against the last, lower, molar tooth. This tooth acts in a piston- 
like manner, pushing the tonsil still further through the loop 
and helping to hold it there. The thumb of the right hand is 
now used to propel the fork whose prongs transfix the cortex or 
the subcortical tissue. By an ingenious device the fork is 
pushed away from the shaft, at the instant of transfixing, thus 
still further enlarging the protruding segment, which is kept in 
place by the fork on one side, by the tooth on the other, and 
also by the encircling loop steadied by both the shaft and the 
chain. Assured that all these supports are firm, the surgeon 
now makes traction with the first and second fingers of his right 
hand, causing the ring knife to cut through the entire mass 
engaged within the loop. The instrument is withdrawn, bring- 



THE FAUCIAL TONSILS 



229 



ing with it the tonsil impaled upon the fork; blood is wiped from 
the raw surface, remaining shreds of tissue clipped off with biting 
forceps, and the fossa packed with picked gauze, to be removed 
when the condition of the denuded tissue gives assurance that 
there will be no further bleeding. Fig. 83 portrays the tonsillo- 
tome in use. 

When the left tonsil is to be enucleated, the instrument is 
introduced so that the distal side of its loop reaches the left 



Fig. 




-Position of the tonsillotome at the moment when the attachments of 
the tonsil are cut. 



posterior, faucial pillar, while its shaft crosses the mouth diag- 
onally, emerging near the right corner. If the surgeon is 
ambidextrous he pulls the chain with his right hand, manipu- 
lating the fork, loop and ring knife with the left. Otherwise, 
each hand does the same work as in removing the other tonsil. 
The left hand, by crossing over above the right wrist, comes into 
a proper position to make traction upon the chain. Other 
details of the technique in operating upon the left tonsil are the 
converse of those followed in operating upon the right. 



230 NOSE, THROAT AND EAR 

By a little practice, one may learn to successfully employ 
this method in removing diseased tonsils of many kinds, includ- 
ing those that are softened, those that are indurated, and those 
buried in very deep fossae. Almost the only exception is a 
tonsil too large for inclusion in the loop. Even this may be 
extirpated by using the largest instrument and by the first 
incision cutting off a segment from the upper part of the cortex; 
then by the second taking a similar piece from the lower part, 
and finally passing the loop over the organ reduced in size and 
cutting it free from its attachments. 

After tonsillectomy by either method, a patient requires the 
treatment recognized by general consent as proper in the post- 
operative state. Its main features are rest in bed, freedom from 
mental and physical exertion, until nervous equilibrium is 
restored, and a bland, unstimulating diet. Abnormalities 
in temperature, pulse rate, or indeed in any function, require 
the attention necessary in such conditions, whatever may be 
their causation, an elementary matter, with which every phy- 
sician is familiar. No local treatment is commonly necessary. 
The raw surface left by the enucleation heals by granulation and 
subsequent contraction reduces the fossa to a small size. 
The velum palati, the f aucial pillars and all contiguous organs, 
perform their functions unaffected by the departure of two of 
their group. There can be no recurrence for the tonsils are 
absolutely gone and with them the disorders and infections of 
protean forms with which they were associated. 



CHAPTER XX 
THE LINGUAL TONSIL 

The lingual tonsil is a lymphoid body situated upon the 
tongue at the median line, slightly posterior to the faucial pillars. 
It may be examined by direct vision, if the mouth be wide open 
and the tongue well depressed, and also by reflection in the 
laryngeal mirror. It presents a slightly elevated, rounded con- 
tour with a central fissure, from before backward, caused by the 
median glosso-epiglottic ligament. Upon its surface are nu- 
merous small nodules with flattened or depressed tops, in each of 
which is the orifice of a duct leading to a mucous gland. These 
nodules consist of lymph cells, the internodular spaces being 
filled with connective tissue. The depressions upon the nodules 
somewhat resemble the crypts or lacunae of the faucial tonsils 
and under the influence of inflammation they become filled 
with a caseous exudate and epithelial debris, which may be so 
abundant as to cover the interspaces and form patches much 
like the membranous exudate seen in cryptic tonsillitis (faucial). 
Branches of the blood vessels of the tongue and a few filaments 
of sensory nerves ramify through the stroma in conjunction with 
lymphatics. The function of the lingual tonsil, if a function 
exists, is unknown. The period of greatest development is 
infancy and childhood and after puberty there is a tendency 
to atrophic change, but this is less marked than in the other 
lymphoid bodies and, in many persons, both size and vascu- 
larity continue unchanged till middle life. 

The lingual tonsil often participates in the inflammatory 
processes affecting other parts of the throat and, quite aside 
from any purpose of ours, comes in for its share in the effects of 
sprays, lozenges and other therapeutic measures, but only two 
conditions are likely to make it the primary object of treatment 



232 NOSE, THROAT AND EAR 

— varicose veins and hypertrophy. The cause of varix in this 
locality is conjectural and has no demonstrable connection with 
the disease in other parts of the body; a long-accepted, popular 
opinion associates it with overexertion, or misuse of the vocal 
organs. Visual inspection shows the surface of the tonsil 
traversed by enlarged blue veins more or less tortuous; to the 
ringer they give the sensation of a compressible body, slightly 
elastic; they are not tender under pressure. Sometimes varix 
exists for a long time, without giving rise to any symptoms, 
being discovered during an examination of the throat having 
some other object in view. When symptoms are present the 
patient complains of pain, which is aggravated by using the 
voice and alleviated by eating; a curious fact as yet unexplained. 
The pain frequently gives the impression that a foreign body 
is lodged in the fauces, pricking and scratching the mucous 
membrane. 

The purpose of treatment is twofold: to stop haemorrhage 
when, in some way, one of the veins has been eroded and there 
ensues considerable bleeding; and to effect a radical cure by 
extirpation of the varix. The bleeding can nearly always be 
effectively arrested by a mixture of equal parts of the tincture of 
chloride of iron and glycerine, topically used with a cotton- 
tipped applicator, or a bead of fused chromic acid lightly drawn 
over the surface after desensitization with an eight per cent, 
solution of cocaine. This is a temporary, palliative measure 
to meet the emergency of such loss of blood as may alarm the 
patient or his friends, though dangerous haemorrhage at this 
spot is rare. Recurrence of the bleeding should be rendered 
impossible and annoying symptoms abolished by the radical 
operation. The best method is to induce local anaesthesia 
with an eight per cent, solution of cocaine and then to draw 
transverse lines over the engorged veins with the electrode of 
the galvanocautery. The temperature must be that signified 
by the cherry-red color of the metal; if a white heat is used, 
there is no haemostatic effect, and indeed, it may cause profuse 
haemorrhage. 



THE LINGUAL TONSIL 



233 



After the extirpation, the patient is apt to suffer considerable 
pain at intervals until the surface under the eschar is entirely 
healed. This pain is felt particularly when food passes over 
the tonsil on its way to the oesophagus, hence the diet must be of 
the blandest description, entirely free from spices and other 
pungent ingredients. I have had good results from a lozenge 
containing one-fifteenth of a grain of cocaine hydrochlo- 
rate. A short time before a 
meal the patient puts this 
lozenge on his tongue and 
allows it to dissolve slowly, 
taking no food until the solu- 
tion is complete. The partial 
anaesthesia produced greatly 
mitigates the pain and pre- 
vents the dread which in sen- 
sitive persons nearly destroys 
normal appetite and proves a 
hindrance to normal digestion. 

The lingual tonsil, like 
others of the group, is liable to 
hypertrophy, here as elsewhere 
characterized by proliferation 
of the cellular elements and 
hyperplasia of the connective 
tissue. As a palliative treat- 
ment, equal parts of tincture 
of iron chloride and glycerine 

may be used with a cotton-tipped applicator. Extirpation 
may be performed under anaesthesia induced by an eight 
per cent, solution of cocaine. The wire snare can seldom be 
employed with advantage because the tonsil's shape furnishes 
little chance to encircle it properly with the loop. It maybe 
grasped by Volsella forceps, or by my faucial tonsil forceps, 
raised as much as possible from the tongue and its basal attach- 
ments severed with a pair of curved scissors, or with a bistoury. 




Fig. 



84. — Hypertrophied lingual tonsil 
in a case of leukaemia. 



234 NOSE, THROAT AND EAR 

When this method is not available, the tonsil may be exsiccated 
by the galvanocautery (cherry-red heat) and allowed to remain 
in place until it is underlaid by granulation tissue and is cast 
off as a dry, devitalized crust. Postoperative treatment, after 
removal of the tonsil, is the same as that pursued after extirpa- 
tion of a varix. Fig. 84 represents a greatly hypertrophied 
lingual tonsil in a patient suffering from leukaemia. 



CHAPTER XXI 
THE LARYNX: FORM AND FUNCTION 

The larynx is situated upon the boundary between the throat 
and the chest. In traversing it, the breath-road leaves the 
cervical region and enters the thorax, so too the food-road in 
descending beyond this plane passes into the oesophagus and 
hence into the stomach, the remainder of its course being ab- 
dominal and pelvic. It is commonly said that the plane of the 
larynx divides the field of the surgeon from that of the internal- 
ist, to whose province belongs the treatment of thoracic and 
abdominal organs. The distinction is convenient, but in strict 
accuracy there remains no region of the body from which sur- 
gery is debarred. When the walls of the beating heart are 
sutured with safety and success, the knife and the needle may go 
anywhere. 1 With few exceptions, the ancient surgery was re- 
stricted to the surface; but mechanical penetration has gone 
deeper and deeper till, to the great honor of laryngology, 
Killian and Chevalier Jackson have discovered foreign bodies 
in the center of the lung and have removed them by way of 
the bronchi with entire success. 

1 It is a notable fact that the limits of surgery remained almost unchanged 
from the first century to the sixteenth and that the extraordinary enlargement 
since then has been due to three discoveries representing three countries: France, 
Scotland and the United States. First came the Frenchman, Ambroise Pare\ 
Early in the sixteenth century, when kings and princes seemed bent on de- 
populating Europe, he introduced the ligation of arteries, saving countless lives 
and revolutionizing the treatment of gun-shot wounds. In the nineteenth 
century Lord Lister of Edinburgh brought in antisepsis, leading up to our present 
practice of sterilization, and Dr. Morton of Hartford (1846) discovered anaesthesia. 
The work of this trio, by either its direct or remote influence, has made every 
region of the human body accessible to surgery and now it seems probable that 
Dr. Crile of Cleveland, by eliminating the dangers of shock, will immensely 
increase the advantages attendant upon capital operations and add a fourth 
name to this group of the world's benefactors. 

235 



236 



NOSE, THROAT AND EAR 



In shape the larynx somewhat resembles the upper part of a 
cylindroid pitcher, with a wide spout (Adam's apple) in front, 
covered by a lid, the epiglottis, hinged to the spout, and having 
its interior cavity open at the bottom. Fig. 85 represents the 
anatomical framework of the organ divested of the membranes 
covering its surface, viewed from the rear. The laryngeal frame- 
work is very complex, no less than nine cartilages taking part in 



Epiglottic cartilage 



Superior cornu of thyreoid 



Corniculate cartilage ■ 



Arytenoid cartilage 




Cuneiform cartilage 



S Thyreoid cartilage 



Inferior cornu of thyreoid 



Median crest 

Fig. 85. — Cartilages of the larynx seen from behind in their natural positions. 

The cuneiform cartilages are somewhat higher than normal. {Merkcl.) 

its composition. They are the thyroid, cricoid and epiglottis, 
which are single, and three occurring in symmetrical pairs; the 
arytenoids, cuneiformae (cartilages of Wrisberg) and cornicula 
laryngis (cartilages of Santorini). These together with their 
articulations, the ligaments attached to them and the interior 
and exterior muscles, some of which are shown in Fig. 86, render 
the structure of the organ especially complicated. Most of 



the larynx: form and function 



237 



this complexity, however, becomes evident only upon post- 
mortem dissection. The living, functionating larynx, the 
larynx with which we deal, presents itself as a single structure; 
its numerous parts are firmly joined into one whole; an organ 
which is firm, but not rigid, which possesses some flexibility and 
elasticity. Its outside surface gives at- 
tachment to a number of muscles which 
move the organ as a whole and which, 
in conjunction with the intrinsic mus- 
cles, alter the relative positions of the 
component cartilages and ligaments. 
Its interior is lined throughout with 
mucous membrane, having near the 
upper margin a squamous epithelium, 
but at the level of the vocal cords and 
upon the surface below them a colum- 
nar, ciliated epithelium. At the junc- 
tion of the larynx with the trachea the 
shape of its internal cavity is cylin- 
drical and this form is maintained till 
above the middle, where the space is 
lessened and altered from a circular 
form to a rectilinear shape which, where 
most widely extended, is almost a tri- 
angle with its apex in front near the 
root of the tongue, and its base in the 
rear near the oesophagus. This is not 
only the most contracted part of the 
laryngeal tube, but the smallest opening through which the 
breath-road passes in its entire course. 

This orifice, called the glottis, or rima glottidis, is in the adult 
male about an inch long and half an inch broad, at its widest 
point; in females both the length and breadth are less. Its 
size and shape are regulated by the two lower thyro-arytenoid 
ligaments, which encroach upon the intralaryngeal space from 
the right and left; when they are furthest apart, the aperture 




Fig. 86. — Posterior view 
of important muscles of 
the larynx and part of the 
cartilages. The thyroid 
cartilage has been re- 
moved. A, epiglottis; B, 
aryteno-epiglottidean mus- 
cle; C, arytenoid cartilage; 
D, arytenoid muscle; E, 
remaining border of thy- 
roid cartilage; F, posterior 
crico-arytenoid muscle; G, 
trachea unopened. 



238 NOSE, THROAT AND EAR 

between them is trianguloid; when they approach each other 
closely, it becomes a mere slit, which is extremely narrow. 
These thyro-arytenoid ligaments are the true vocal cords, the 
chief organs of the voice. Each one consists of a single, strong 
band of elastic, fibrous tissue, attached in front to the thyroid 
cartilage and behind to the arytenoid: the band is covered by 
mucous membrane, very thin and very firmly adherent. By 
enveloping this fibrous strand the mucosa forms a narrow rib- 
bon of two layers, each of which is reflected over the contiguous 
surTace, one above and one below, thus becoming continuous 
with the mucosa, which lines the inner surface of the laryngeal 
walls. The result is that the ribbon of folded mucous membrane 
is attached along its outer margin to the walls of the larynx, 
while its inner margin is free and movable; this free inner margin 
envelops the fibrous strand or cord, which is thus capable of 
vibratory movement and can be relaxed or made tense. The 
entire ribbon-like structure, including the elastic, fibrous band 
and the overlying mucous membrane, is commonly designated 
the vocal cord. Our usual concept of a cord is that of a strand 
or string, fastened at the extremities, but otherwise unattached 
and free to vibrate by curving in any direction. A vocal cord 
does not comport with this description; it is not a free string, 
but a membrane with one free margin or border and this border 
can vibrate up and down; but only in these directions, as in- 
spiration curves the border downward and expiration curves it 
upward. The band's elasticity causes its resumption of its 
habitual position, after each impulsion in either direction. 
Situated a little above the vocal cords and separated from them 
by two narrow fossae, called the ventricles of the larynx, are 
two longitudinal folds of mucous membrane, termed the false 
vocal cords because, while resembling those just described in 
some particulars, they do not take part in producing the voice, 
though they may have a modifying influence. Fig. 87 gives 
the image of the larynx seen in the laryngeal mirror. 

The larynx has two functions: respiration and phonation. 
In respect to the first, it serves as one section of the breath-road, 



the larynx: form and function 239 

connecting the passageway of the pharynx with that of the 
trachea, and this section has peculiar characteristics due to the 
fact that the glottis is the smallest orifice through which air 




( 



\ 




Fig. 87. — An entirely normal larynx, as reflected in the laryngoscope. A, left 
arytenoid cartilage; C, left vocal cord; E, epiglottis. Observe that these struc- 
tures upon the left side of the throat appear on the right side of the reflected 
image. Such lateral reversal always occurs in a mirror. Remembrance of this 
fact will prevent the confusion so common in illustrations of the larynx and of 
other organs seen in reflected images. 

currents pass. This has much clinical importance; for at this 
point there is great liability to obstruction, either by the lodge- 
ment of foreign bodies, or by obstacles produced in the course 



240 



NOSE, THROAT AND EAR 



of disease. If the larynx is occluded, there is no collateral 
route for the passage of air, such as the mouth supplies when 
there is closure of the nares, and fatal suffocation can be pre- 
vented only by opening an artificial route, as is done in trache- 
otomy; or by some other expedient, which will bring oxygen to 
the lungs. 

The older physiologists were not far from the truth in desig- 
nating the larynx as the organ of voice; for the part it plays is 
preeminent, while that of the various chambers, resonating 



Cuneiform tubercle 
Corniculate tubercle 



Arytenoid muscles 



Lamina of cricoid 




Median glosso-epiglottic fold 
Epiglottis cartilage 



Appendix of the ventricle 
Ventricular fold 



Ventricle 
Vocal fold 
Thyreoid cartilage 

Median crico-thyreoid ligament 



Arch of cricoid 
Crico-tracheal ligament 
First tracheal cartilage 



Fig. 



-Vertical section of the larynx in the median line. (Merkel.) 



cavities, is wholly subordinate. Remember we are considering 
voice, not articulate speech. Many organs between the larynx 
and the lips cooperate in making sound articulate; that is, in 
converting voice into speech; but the production of voice itself 
is primarily and chiefly the function of the glottis and vocal 
cords and a few contiguous structures which are portrayed in 
Fig. 88, representing the left half of the organ displayed by a 
vertical division along the median line. 



the larynx: form and function 241 

The preeminence of the larynx in producing the voice has 
long been well known; but even today there are many who 
hold the belief, anciently prevalent in most countries, that the 
tongue is the chief organ of phonation, a belief expressed by 
using the same word for the organ and for the language; as we 
say: teaching the English tongue, translated into the English 
tongue. The same connection of thought is shown in Greek, 
Latin, Italian, Spanish and many other languages. As a matter 
of fact, the tongue takes no part in the production of voice, 
though it aids in articulation. 

The mechanism of phonation is similar to that of reed instru- 
ments, in which a thin lamina is put in vibration by a current 
of air. When the vocal cords are fully relaxed and the glottis 
is open to its full capacity, the air in both inspiration and ex- 
piration passes through the larynx, without producing any 
sound; but when these conditions are changed by muscular 
action, sounds are produced and their pitch and volume depend 
upon the character of the muscular contractions. There are 
eight objects in the actions of the laryngeal musculature: to 
lengthen the vocal cords, to shorten them, to relax them, to 
render them tense, to elongate the glottis, to shorten it, to nar- 
row and to widen it. A ninth action pertains to the thoracic 
and abdominal muscles, which, bellows-like, impel the current 
of air passing upward through the larynx. These nine muscular 
acts are capable of a very large number of combinations and it 
is by their interaction and coordination that the widely varied 
phenomena of phonation are produced. It is true that there 
exists a likeness between the mechanism of the vocal organs 
and the mechanical construction of musical instruments with 
vibrating reeds; but it is not true, as often asserted, that such 
instruments were made in imitation of the human larynx; for 
those of the type whose similarity is greatest were in use long 
before the physiology of vocalization was understood. 

The tones as produced by the vocal cords are modified by 
harmonics, or overtones, added by the vault of the naso-pharynx, 
roof of the mouth and nasal sinuses. If these resonating cham- 
16 



242 NOSE, THROAT AND EAR 

bers are obstructed by hypertrophies or neoplasms, the voice 
takes on a rasping, harsh, or muffled quality but the number of 
octaves within its compass is but little affected. This compass, 
or register, depends upon the vocal cords and is the same for 
boys and girls before puberty but at that age the larynx in the 
male greatly increases in size, the cords are elongated and the 
pitch of the voice becomes much lower, producing what are 
called the bass tones. In the female, puberty has little influ- 
ence upon the pitch and hence opera, oratorio and choir singers 
are usually chosen from both sexes, the soprano and alto parts 
being taken by women, and the tenor, baritone and bass by men. 
There is, however, a certain quality in the voices of young boys 
which is found in no others; this quality is highly prized by 
some eminent musical conductors and hence boy choruses are 
maintained in spite of the inconvenience and trouble entailed 
by the fact that the singers are constantly changing, the first 
sign of puberty compelling their retirement. 1 Much has been 
said of the difference between the singing and speaking voices, 
but their method of production is the same and the most valid 
distinction is that, in speaking, far more attention is given to 
distinctness of articulation and little use is made of either very 
low or very high tones, while, in singing, the creation of these 
tones at the upper and lower extremities of the register is greatly 
valued, as is also great clearness and accuracy in the production 
of each note. 

The gift of voice is restricted to a small part of creation. The 
whole inanimate world is mute, so also is the vegetable kingdom 
and all of the animal kingdom below the vertebrates; even 
among the vertebrates the almost numberless fishes and most 
of the reptiles are voiceless. The birds and mammals have 
phonation, but within very narrow limits, for even the most 
intelligent of the lower animals, like the dog, can utter but few 
sounds. In contrast with the wonderfully varied effects of 

1 In some churches the choirs are composed exclusively of men and boys, 
because the highest ecclesiastical authority forbids the participation of women 
in the musical service. This was the general church custom down to the sixteenth 
century. 



the larynx: form and function 243 

which the human voice is capable, the dog's vocalization is ex- 
tremely slight and indicates the wide gulf that separates him 
from man. Phonation also shows the solidarity of the human 
race, for the degraded Melanesians of the south Pacific have 
vocal capabilities that differ but little from those observed 
among civilized peoples of the highest type. One thing the 
domesticated dog has learned in his long association with man, 
he can bark, while his wild relatives, the hunden of South Africa 
and the jungle dogs of India have only howls, yelps, and growls. 
This solitary acquisition by the most intelligent of brutes is 
almost pathetic in its proof that he cannot pass the chasm 
separating him from man whose companion he has been through 
the ages. The man- reared dog had learned to bark three thou- 
sand years ago and has learned nothing more since that time. 



CHAPTER XXII 
LARYNGITIS 

Acute laryngitis may occur as a primary affection, but it is 
much more commonly secondary to inflammations of the phar- 
ynx and intranasal canals; these are the chief predisposing causes. 
Among others, is the overexertion of the voice or faulty meth- 
ods in its use, a sedentary life passed in rooms poorly ventilated 
and indigestion, either gastric or intestinal. Many text books 
add the rheumatic diathesis, and this constitutional condition is, 
without doubt, often present in those subject to laryngitis and 
other throat troubles, but it is questionable whether the so- 
called diathesis bears a causal relation to the laryngeal affection. 
Perhaps both are merely synchronous and owe their origin to a 
common cause. 

Simple laryngitis is most common in children and young 
adults, and affects nearly an equal number of males and females. 
Its exciting causes include sudden vocal strain, like that pro- 
duced by oratorical efforts in the open air by one unaccustomed 
to loud speaking out of doors, a very common experience of 
candidates in political campaigns; also the inhalation of irritant 
particles of dust and smoke and noxious fumes given off in dye- 
houses and manufactories of chemicals. By far the most com- 
mon exciting cause, at least in the estimation of the patients 
themselves, is the incident called "catching cold," an experience 
familiar to almost every one who lives in a changeable climate, 
subject to sudden variations in temperature and barometric 
pressure. As has been said already, the quick disturbance of 
the balance between the pressure within the body and without, 
causes an increased flow of blood to the mucosa, the thinnest 
partition separating the inside and outside, with consequent 
congestion, perhaps inflammation. These phenomena, when 



LARYNGITIS 245 

they occur near the glottis, are specially serious, because of the 
narrowness of the space, due to which any swelling following 
engorgement must extend in the direction of the center, where 
there is little room to spare. 

Usually the first symptom noticed is a change in the voice 
which is hoarse, muffled or squeaky; in some instances the func- 
tion is suddenly suspended, as when the patient, on rising in the 
morning, finds he cannot make himself heard, the changes 
causing loss of voice having occurred during his sleep. In 
addition to this, there is some soreness in the laryngeal region 
and the front of the throat may be tender under pressure. 
Soon a cough develops; at first short and dry in quality, later 
becoming prolonged and moist. Expectoration soon appears, 
beginning with watery mucus, scanty in amount, but later 
becoming free, thick and purulent, if the inflammation is suffi- 
ciently severe and extensive to attract many leukocytes to the 
part. The laryngoscope shows the mucous membrane generally 
to be congested and of a deeper red than normal; the cover- 
ing of the vocal cords, which is very thin and usually pale in 
color, may acquire the crimson tint of the contiguous structures, 
though this change does not always occur. Often the cords are 
swollen and there may be edematous enlargement in the mem- 
brane just below their attachment, an enlargement that can 
be seen through the orifice of the glottis. This is of serious 
import, as the narrow passageway may readily be occluded. 

Constitutional symptoms may be absent, or there may be 
malaise, thirst, anorexia and the other phenomena associated 
with slight pyrexia. 

In treatment, the indispensable factor is rest for the vocal 
organs. The use of the voice must, for the time, be forbidden. 
No exception can be made for whispering, although there is 
prevalent a fallacious belief that it is harmless; on the contrary, 
the muscular contractions required by loud phonation are also 
needed to produce the whisper, in which the volume or intensity 
of sound is very slight, but nevertheless the escaping air has 
been phonated before it reaches the organs of articulation, 



246 NOSE, THROAT AND EAR 

otherwise no sound whatever would be heard; the phonogenetic 
vibrations are required in the whisper and to produce them tires 
the muscles and is incompatible with the absolute rest which is 
needed. The patient should be confined to a well-ventilated 
room whose temperature is uniformly kept at 72 F. and 
whose atmosphere is rendered moist by steam. He should 
have a plain, nonstimulating diet, with an abundance of water 
and also fresh milk, unless that proves unsuitable, as it 
does with some adults, though always available for children. 
Alcohol, tobacco, coffee and tea are prohibited. Chocolate and 
cocoa may be used, as also orange juice and lemonade — a con- 
cession to the taste of persons who are habituated to drinks 
other than plain water. Full and free action of the bowels is 
to be secured by small doses of calomel given at short intervals 
and followed by a saline cathartic. To promote secretion and 
relieve the cough, I advise the following sedative expectorant: 

]$. Codeine sulphate gr. iij 

Antimon. et potas. tart gr. ij 

Liq. potas. citrat q.s. ad. fl. §iij. M. 

S. Take a teaspoonful every two hours. 

Inhalations of vapors prove serviceable, particularly that of 
benzoin. To one-third of a pint of water at the ordinary tem- 
perature, add two-thirds of a pint of boiling water and a fluid- 
drachm of the compound tincture of benzoin; over the top of the 
jar or other vessel holding this mixture, adjust a funnel made 
from a folded towel which will convey the medicated vapor to 
the upper respiratory tract. 

During the first stage, it is beneficial to spray the nose and 
fauces with Dobell's solution. After secretion is well estab- 
lished, it is well to employ stimulating expectorants, such as 
ammonium chloride gr. v, combined with codeine or with Dover's 
powder. At this stage also, there is advantage in applying 
astringent sprays directly to the larynx by means of an atomizer 
with a curved tube guided to the proper position by the image 
in the laryngeal mirror. A good solution for this purpose is 
made by dissolving from three to five grains of zinc sulphate 



LARYNGITIS 247 

in a fluidoimce of sterilized water. Under such treatment, 
recovery generally takes place, without leaving any permanent 
injury to the voice or any other function. Some persons are 
prone to recurrent attacks and examination usually shows that 
they have abnormal conditions in the nose, pharynx, or tonsils 
acting as permanent predisposing causes. These abnormalities 
should be dealt with in a thoroughgoing way and it will be found 
that their correction puts an end to the repeated attacks of 
laryngitis. 

Spasmodic or night croup, also called false croup, to distin- 
guish it from the pseudomembranous variety, seldom comes 
under the care of a specialist, because the attacks occur suddenly 
in children previously in their ordinary state of health and ex- 
clusively at night. Where a close watch has been kept, it has 
been found that during the preceding twenty-four hours there 
are some prodromes, such as a slight rise in temperature and 
acceleration of the pulse rate with restlessness and general dis- 
comfort, but in the great majority of cases these things are 
overlooked. The child goes to bed at its usual time and falls 
into a deep, heavy sleep; at midnight or in the early morning 
hours, it suddenly starts up with a cry of terror and begins to 
struggle for breath, catching at its throat and swaying from side 
to side, while its eyes are wide open and staring and its lips and 
nostrils have the cyanosed tint of suffocation. The distress of 
the little patient is extreme; there is the sense of strangulation 
and, in those old enough to reflect, the dread of impending death. 
Many a gray-haired man vividly recalls the terror and anguish 
of those attacks and avers that, among all the multiform pains 
of fifty years, none have been worse than these sufferings of 
childhood. The pathology of false croup is the same as of 
simple, catarrhal laryngitis, with the addition of a neurotic 
element causing the muscular spasm by which the glottis is 
closed, giving rise to the torturing suffocation. 

A fatal termination is rare, because spontaneous relaxation 
occurs as carbon dioxide accumulates in the lungs. Of course, 
we do not wait for this with the suffering and other evils delay 



248 NOSE, THROAT AND EAR 

entails. To relax the spasm by treatment is the first object in 
view and an admirable remedy is a few minims of chloroform 
dropped upon a handkerchief and inhaled. It is a thoroughly 
safe remedy and the relief it gives is often magical. Though 
it has no effect on the inflammatory process in the larynx, it 
secures at least a partial relaxation of the suffocating spasm 
and greatly lessens the child's distress while other measures of 
treatment are in preparation. For thorough relaxing and al- 
terative effects the hot bath proves very efficient. The comfort 
it gives is so great that the child is apt to fall asleep in the water. 
If facilities for the bath are not at hand, sponges or towels 
steeped in hot water may be applied to the throat with good, 
though minor effects. Emetics are also valuable, for the re- 
vulsive influence of vomiting produces muscular relaxation and 
in addition, the stomach is emptied of food which has remained 
there for many hours only partially digested. The emesis 
often, not always, brings to light a condition of gastric indiges- 
tion which had not been suspected, but which doubtless played 
a part in provoking the attack of croup. Ipecac, in the form 
of either the syrup or wine, should be administered in doses of 
one or two teaspoonfuls, according to the age of the patient. 
It is one of the most trustworthy emetics and also quite safe, 
as its action terminates with the expulsion of the gastric con- 
tents. There are no depressing constitutional effects. 

After convalescence from the acute attack, attention should 
be given to prevent recurrence. For this purpose the following 
mixture is useful : 

]$. Tine, aconiti rad TTUxiv 

Potas. citratis 5 j 

Potas. bromidi gr. xl 

Syr. ipecac fl. 5 j 

Syr. limonis fl. §j 

Aquae q.s. ad. fl. 5"j- M. 

This may be administered every two hours in doses adapted 
to the child's age; a teaspoonful is suitable at two years. Hy- 
gienic measures also are of importance. The physician should 



LARYNGITIS 249 

look into the child's diet, habits and manner of life. He will 
probably find a number of things which need correction, and 
if the parents are wise enough to follow his advice and adapt 
their child's environment to its age, strength and mental and 
physical qualities, it is likely to have but few attacks of croup 
or, indeed, of any other illness. 

(Edematous laryngitis is characterized by an engorgement 
occurring beneath the mucosa, especially where it is loosely 
attached to the submucous structures, as in the ventricle of 
the larynx. The fluid producing this engorgement is mainly 
serum with an admixture, greater or less, of the other constitu- 
ents of the blood, and the color of the cedematous surface is pale 
or red, in proportion to this admixture. In the laryngeal mirror 
the vocal cords appear swollen, encroaching upon the orifice of 
the glottis; sometimes the oedema is most marked in the tissues 
above the cords, sometimes in those below, sometimes in the 
strands themselves. In all cases the effect is to diminish the 
size of the glottis. The voice is husky, muffled, or perhaps 
wholly suppressed, there is a harsh, short cough and more or 
less pain, but the symptom which predominates, both in the 
sensations of the patient and in its clinical significance, is the 
dyspnoea due to the impaired respiration. For the time being, 
other things are insignificant, as the patient's life depends on 
keeping open the breath-road or, if it is closed, on creating 
some substitute passageway. 

Why certain cases of laryngitis should develop oedema of the 
glottis, while the majority pass through all their stages without 
producing it, has been a debated question and various explana- 
tory theories have been brought forward, but they are conjec- 
tural and of little value to the clinician. 

Treatment has three objects: first, to deport the accumulated 
fluid; that failing, to evacuate it and, if respiration be still 
seriously embarrassed, to maintain a breathing route, in spite 
of it. The first procedure is successful in certain mild cases 
where the swelling is moderate and stationary; it includes re- 
duction of the somatic content of serum by active purging with 



250 NOSE, THROAT AND EAR 

cathartics which produce large, watery stools, such as Epsom 
salts, together with the induction of topical ischaemia by putting 
an ice bag upon the throat over the larynx, holding ice frag- 
ments in the mouth and applying epinephrin chloride (solution 
of 1 : 1000) to the cedematous membranes either by the spray 
from an atomizer or with a cotton-tipped probang, directed by 
the laryngeal mirror. The second procedure resorted to, pro- 
vided success does not attend the measures mentioned, is free 
scarification with a lance blade attached to a curved shank and 
guided by the mirror. The serum, blood, liquid of any kind 
which distends the membranes is to be evacuated and ejected 
from the mouth, caution being observed to keep the trachea free 
from it. If such treatment proves unsuccessful, or without 
resorting to it in fulminating cases, where the symptoms of 
asphyxia grow rapidly more and more threatening, the third 
procedure is demanded; the last resort, making a substitute 
route for respiration, so that it can be maintained irrespective 
of the occluded glottis. This final resort is tracheotomy and 
many surgeons turn to it reluctantly, both because of its in- 
herent difficulties and because this artificial passageway de- 
livers the air to the lungs in a state liable to cause serious trouble, 
since it has not had the preparation it receives when normally 
taken through the nose and pharynx. Nevertheless, if tra- 
cheotomy appears to be necessary, there should be no loitering; 
the patient's chances grow momentarily less if the oxygenation 
of his blood is hindered, and action should closely follow de- 
cision. It is a wholly mistaken conservatism which delays a 
necessary operation until the patient is moribund. 

Chronic laryngitis has two varieties: the catarrhal and the 
atrophic. The *first is commonly a prolongation of the acute 
form and exhibits that abatement in the symptoms and physical 
signs which is observed in so many morbid states, when there 
has come about a sort of compromise between the malady and 
the organism. The body establishes some tolerance of the 
disease and the mind adapts itself to the abnormal conditions, 
so that the patient learns to live and work with some functions 



LARYNGITIS 25 1 

crippled. In the category of causes of the chronic variety, 
in addition to repeated and inefficiently treated acute attacks, 
are abnormal conditions in the nose, fauces and naso-pharynx, 
especially adenoids with the consequent mouth breathing, and 
also continued misuse of the voice. 

The symptoms are a feeling of constriction and dryness, a 
dry hacking cough with scanty expectoration of white, stringy 
muco-pus. The voice is hoarse, trembling and easily fatigued. 
Usually there is no dispncea or dysphagia. The laryngoscope 
shows the mucous membrane to be in a state of sub-acute in- 
flammation with punctuated irregularities of surface, enlarged 
glands and many abrasions, particularly in the interarytenoid 
spaces. Actual ulceration is exceptional, a diagnostic point 
in differentiating this catarrhal type from the forms due to 
infections. 

Treatment is primarily influenced by the etiology of the 
affection. It is indispensable to correct abnormalities in the 
nose, naso-pharynx and fauces which play such a mischievous 
part in all diseases affecting the breath-road. So too the dis- 
orders of metabolism, whether indicated by dyspepsia, con- 
stipation or any other form of indigestion, must have careful 
investigation and appropriate treatment; for unless the nutri- 
tive functions are properly performed, special organs cannot 
be maintained in a normal state, much less restored after 
illness. As to the rheumatic and gouty diatheses, so called, 
which are manifested by arthritis and the varied myalgias, it 
matters little in our therapeutics whether these dyscrasias are 
causal or only coincident; it is plain that they point to morbid 
constitutional conditions which aggravate the throat disorder 
and, if they are corrected by appropriate treatment, the throat 
will be benefited. The voice must have rest until there is 
improvement in its quality, and the faulty method of using it, 
which is a frequent etiological factor, should be supplanted by a 
proper phonation. In some instances excellent results have 
followed a vocal training corrective of former mistakes, the 
method being devised by the physician and teacher in coopera- 



252 XOSE, THROAT AND EAR 

tion. Where the patient's occupation exposes him to smoke, 
dust, or irritating vapors, a change in vocation may be neces- 
sary to a cure. Alcohol and tobacco are to be avoided and\he 
best hygienic conditions available should be maintained. 

In addition to the foregoing measures intended to eliminate 
the predisposing causes, topical treatment of an alterative 
kind has much value in counteracting the damage done by the 
inflammation and restoring the functional activity of the organ. 
Dobell's solution should be employed for the thorough cleansing 
of the entire respiratory tract above the plane of the larynx, and 
should be used by the patient, in the intervals of office visits, 
to remove secretions and any impurities left by the inspired air. 
After the membranes have thus been cleaned of extraneous 
matter, a spray may be directed upon the vocal cords by an 
atomizer tube of downward curve, guided by the mirror. The 
solution for this purpose consists of two to five grains of 
either zinc sulphate, or zinc sulphocarbolate to the fluidounce 
of sterilized water. To secure healing of the abrasions, which 
are a prominent feature, it is often necessary to use astringents 
of greater power, and I find the zinc salts just mentioned efficient 
if the strength of the solutions is increased, making them ten 
grains to the fluidounce. When the abrasions are persistent and 
the zinc salts are tardy in action, as sometimes occurs, I recom- 
mend the application of a two per cent, solution of silver nitrate. 
These stronger remedies must be used with a cotton-tipped, 
laryngeal applicator, moist but never dripping. With the silver 
salt, especially, care must be taken that none of the solution 
drops down into the trachea. Stimulating expectorants are 
adjuvants to these topical measures. Lozenges of ammonium 
chloride, each containing two grains, or of ammonium iodide 
containing one grain, answer the purpose and five or six may 
be allowed to dissolve in the mouth during the course of a day. 
The progress of a patient toward recovery is sometimes inter- 
rupted by an exacerbation of the disease which, without any 
assignable cause, suddenly shows a recrudescence of acute symp- 
toms. Under such circumstances, we must suspend, for the 



LARYNGITIS 253 

time being, the stimulating treatment and recur to the sedative 
therapeusis appropriate in an acute attack. An incident like 
this is apt to discourage the patient who fears that the improve- 
ment has been counteracted and that he is thrown back to the 
worst stage of the disease, but his mind may be set at rest for 
these recrudescences soon yield to treatment; the gains made are 
found to be permanent, and the progress toward recovery is 
soon resumed. 

The atrophic variety of laryngitis is generally secondary to 
atrophic changes in the nose or pharynx; when these are present 
the morbid conditions in the three localities must be considered 
together. The pathologic findings indicate that the mucous 
membrane has undergone a retrograde change. The ciliated, 
columnar epithelium gives place to one of squamous type; the 
mucous glands grow few, or disappear; the blood vessels are 
contracted and, in consequence, the secretions are of lessened 
amount and denser consistency so that they dry into crusts whose 
color is gray, brown, and occasionally nearly black. All the 
tissues affected show a tendency to dessication and from this 
circumstance the disease has been called laryngitis sicca. 

A very frequent symptom is a pricking, burning sensation, 
following the use of the voice, especially if there has been an 
effort to produce tones of large volume, or high pitch. A hoarse, 
spasmodic cough is incited by the crusts and the futile efforts 
to dislodge them. These crusts may encroach upon the glottis, 
particularly during the hours of sleep, and the patient be 
awakened by suffocative symptoms which resemble those of 
spasmodic croup. The laryngeal mirror shows the mucosa 
to be pale and shrunken, while the vocal cords appear wrinkled ; 
in addition to the crusts, there may be some ulcers in a state of 
active purulency, chiefly located near the posterior margin. 

Treatment follows the general course laid down in discussing 
atrophic rhinitis (Chapter VII) and often includes it, as the two 
disorders may be simultaneously present. Locally, Dobell's 
solution should be applied to the larynx by a spray or a pro- 
bang, so as to remove all crusts and thoroughly cleanse the 



254 NOSE, THROAT AND EAR 

affected surface. The next step is to produce such an alterative 
effect that the retrograde changes will be stopped and as much 
restoration as possible secured in those structures, which have 
begun to shrink. Here, as in other localities, our best remedy is 
iodine, and for laryngeal use it is preferably administered in 
the form of nosophen (tetraiodophenolphthalein) . The follow- 
ing mixture can be employed either as a spray, or with a swab : 

fy. Nosophen gr. ii 

Menthol gr. iii 

Olei Olivse fl. o J- M. 

If ulcers are found, they should be touched with a two per cent, 
solution of silver nitrate, applied with the precautions already 
emphasized. 



CHAPTER XXIII 
LARYNGEAL INFECTIONS 

There are three infectious diseases whose pathogenic germs 
frequently invade the larynx, coming either from the inspired 
air or through the blood, and which either directly, or by their 
toxins, originate morbid processes of a distinctive kind and of 
serious import. These are tuberculosis, syphilis and diphtheria. 
Laryngeal manifestations observed in the other contagious fe- 
vers are symptomatic of the con- 
stitutional disorder and rarely 
produce any throat lesion of im- 
portance. 

Laryngeal tuberculosis (Fig. 
89) also termed consumption of 
the throat and laryngeal 
phthisis, is sometimes primary, 
but much oftener secondary ^ to 
the pulmonary variety; that is 
to say, the pathognomonic 

right vocal cord is hidden by swell- pear in the throat until a con- 
ing in or above the ventricle on that . , , , . . . . 

side. {Taylor.) siderable time after it is well es- 

tablished in the lungs. This fact 
may be interpreted in different ways. Many think that the 
toxin existing abundantly in the infiltrated pulmonary tissue 
spreads to the larynx by continuity of surface, by the blood 
and lymph circulation, or by the current of expired air. This 
theory requires us to accept two improbable suppositions: 
first, that the myriad bacilli, borne on the inspired air, pro- 
ceed directly to the lungs, via the trachea and bronchi, none 
of them breaking their journey at the larynx through which all 
must pass; second, that with so many avenues available for 

255 




256 NOSE, THROAT AND EAR 

spreading the infection from its pulmonary focus, the larynx 
usually remains uninvaded until a comparatively late stage of 
the disease so that the supervention of throat phthisis is an omi- 
nous prognostic. The observed sequences in the chest and 
throat symptoms are explained more logically by presuming that 
many of the immigrating germs do stop in the larynx, but fail 
to effect a lodgment because the mucosa underlaid by vascular 
cartilage is a resistant structure, able to repel them. So, too, 
there is repulsion against microbes carried by the expired air and 
there is antagonism to the toxins sent forth from the focus in the 
lung. The larynx is like a fortified castle, holding out against 
an enemy who has subjugated much of the surrounding terri- 
tory. When at last, by the weakening of the vital powers, re- 
sistance begins to slacken, then the hostile germs and their tox- 
ins gain a foothold in the larynx and the progress of disease is 
often rapid. I offer this theory because it avoids two im- 
probable suppositions and also because it accounts for the mi- 
nority of cases in which the laryngeal affection is primary, 
cases otherwise quite unexplained. In these instances the germs 
find a lodgment in the larynx at the very start, prior to any 
pulmonary infiltration, because the resistant power of the organ 
has, in some way, been impaired. Such impairment is common 
in many structures and might occur in the larynx as the result 
of antecedent traumatism, operative or accidental, as well as 
from long-continued irritation and congestion, injuring the 
walls of the blood vessels and preventing that rapid concentra- 
tion of defensive leukocytes by which normal organs resist and 
overcome infection. 

One of the first symptoms of tuberculosis in the larynx 
is a change in the voice. It becomes weak and thin, often giv- 
ing the impression that the pitch has been raised, although it 
may be proved by tests of the vibrations that there is hardly any 
change in this respect. This vocal attenuation may go on to 
complete aphonia. As a diagnostic sign, the voice quality dif- 
ferentiates between tuberculosis and syphilis, the latter disease 
producing a harsh, raucous sound of normal volume. There 



LARYNGEAL INFECTIONS 



257 






is a short, hacking cough, with little expectoration, unless there 
exists coincident suppuration in the lungs. At the beginning 
there is soreness, increased by swallowing and speaking, but not 
much acute pain; after ulcers have 
formed, the pain may be very severe. 
Paleness and swelling of the mucosa 
are shown by the mirror, but the 
glottis is not much narrowed and 
hence dyspnea is not marked. 

Tubercular ulcerations are a char- 
acteristic feature; they appear upon 
the vocal cords and the surface of the 
cartilages, particularly the aryte- 
noids, thus showing a tendency to 
break out upon the posterior part of 
the organ, while syphilitic ulcers are 
much more apt to occupy the anterior section. They are 
shallow depressions of a dirty red color, with ill-defined edges 
merging into the unaffected mucosa of the intervening spaces. 
Their exudate is a thin, grayish muco-pus, sometimes streaked 



Tuberculosis of 
The true vocal 
been destroyed. 



Fig. qo.- 
the larynx, 
cords have 

There is infiltration and ulcera- 
tion of the ventricular bands, 
also infiltration of the arytenoid 
cartilages and interarytenoid 
space. 




Fig. 91. — Tubercular growths in 
papillary form occupying the in- 
terarytenoid space of the larynx. 




Fig. 92. — Tubercular infiltra- 
tion of arytenoid cartilages and 
the true vocal cord upon the right 
side of the larynx. {Stout.) 



with blood from abrasions and containing numerous tubercle 

bacilli. Figs. 90, 91 and 92 are reproductions of laryngoscopic 

images, showing lesions of the vocal cords and adjacent tissues. 

The first indication for treatment is to control the constitu- 

17 



258 NOSE, THROAT AND EAR 

tional disease; unless this is done the throat lesions will not im- 
prove, indeed they will almost certainly grow worse, for the 
blood will not be able to furnish plastic material to repair the 
damaged tissues. Nearly every conceivable treatment has been 
used in tuberculosis and the profession, as well as the public, has 
many times been misled by false hopes. The consensus of 
opinion, at the present time, puts chief confidence in the early 
and persistent employment of roborant measures, which aid the 
organism to antagonize the microbes and toxins, together with 
aseptic precautions to reduce to a minimum the further ingress 
of pathogenic agents. To be successful, these methods of treat- 
ment must take into account the patient's traits, idiosyncrasies 
and former habits of life; the effort to enforce a uniform rule 
of conduct is sure to fail. It is specially important to consider 
patients' financial and domestic circumstances, for the plan for 
restorative, hygienic living must be not only desirable, but also 
possible to carry out. The advice to make a long journey for 
a change of climate, given to a man who can hardly afford a 
week's end trip to the seashore, is merely mocking his misery. 
A certain diagnosis, corroborated by a bacteriological test, 
should be made as soon as possible and the patient should be 
frankly told his condition and how important it is that he should 
faithfully carry out the treatment advised. If it be possible, he 
should follow an outdoor occupation, with active though not 
laborious work in the sunshine and open air. If this is not pos- 
sible, his leisure and recreation hours should be spent in such 
surroundings. He should sleep either in the open air or in a 
room whose thorough ventilation makes its atmosphere nearly 
identical with that outside. Muscular exercise is beneficial, if 
not carried to the stage of fatigue. The garments worn next 
the skin should be of absorbent material to take up cutaneous 
secretions; the clothing over these ought to consist of fabrics 
which conduct heat slowly, so that the body may have some pro- 
tection from the quick changes in temperature characteristic of 
our climate. Of course, the weight of clothes worn must be care- 
fully adapted to the season. 



LARYNGEAL INFECTIONS 259 

The popular idea of a diet for tubercular patients is "high 
feeding." If this is understood to be a liberal supply of nourish- 
ing, agreeable food in large variety, it is right, but if it means to 
eat as much as possible, it is very far wrong. It is not the whole 
sum of food which nourishes the body, but only that part which 
is assimilated, so the power of assimilation must be the measure 
of quantity. Besides this, a check is imposed by the power to 
eliminate catabolic, or waste, products. Overfeeding with 
proteins may induce disease of the kidneys, a deplorable compli- 
cation in a case of tuberculosis. The eggs and milk diet has 
sometimes been carried to a most injurious excess, even in sana- 
toria claiming close scientific supervision. The only way to se- 
cure for a patient a really suitable dietary is to watch the effects 
of the aliment taken, as to kind, quality and quantity, within 
the limits set by assimilation and elimination, and to follow the 
teachings of that experience. 

If the constitutional condition shows improvement, we may 
expect amelioration of the laryngeal lesions and can assist the 
process by local treatment. The control of the cough is im- 
portant and all irritating substances whether drinks, vapors, 
dust or smoke must be avoided. The use of the voice often 
proves an irritant and it is best to forbid all phonation, including 
whispering as well as singing and speaking. This prohibition 
proves, at first, a trial to female patients, but they soon grow 
accustomed to it and revert to the sign language with which one 
readily learns to express the ideas whose communication is 
most needful. Intralaryngeal injections do good service by 
modifying the cough and liquefying the secretions. Each day 
from ten to twenty minims of the following combination should 
be applied to the interior of the larynx with a syringe having a 
curved delivery tube and conical nozzle: 

1$. Menthol gr. v 

Creosote gr. v 

Eucalyptol TTlvj 

Guaiacol TUvij 

Olive oil q.s. ad. fl. 5 J- M. 



2 6o NOSE, THROAT AND EAR 

Topical treatment of areas of infiltration varies in accordance 
with their extent. In all cases thorough cleansing of the larynx 
with D obeli's solution is required at least twice daily and oft- 
ener, if there is rapid accumulation of the discharges. This may 
be all that is necessary for it is best not to disturb small infil- 
trations, trusting that they will disappear as the constitutional 
condition improves. Infiltrations, however, causing symptoms 
either obstructive or painful, should be removed. This is best 
effected by cocainizing them with a twenty per cent, solution, 
the application being repeated in five minutes, and then des- 
sicating them with the galvanocautery at a cherry-red heat. 
This is followed by insufflation of iodoform powder, or one of its 
substitutes. The subjoined combination may be used : 

1^. Morpbioe sulphatis gr. iv 

Thymolis iodidi gr. x 

Acidi tannici gr. v 

Bismuthi subnitratis B ss 

Pulvis accaciae q.s. ad. §j. M. 

Ulcers require to be thoroughly cleansed with Dobell's solu- 
tion, anaesthetized with a twenty per cent, solution of cocaine 
and then cauterized by applying lactic acid with a cotton- 
tipped probang, using at first a fifty per cent, solution and gradu- 
ally increasing the proportion of the acid, until full strength is 
reached. The use of the galvanocautery is an alternative 
procedure. The healing of the cauterized surfaces is promoted 
by insufflation with powders such as that above described. If 
dysphagia is especially severe, eating should be preceded by 
applying a four per cent, solution of cocaine with a probang, or 
a few drops of an eight per cent, solution as a spray. Lozenges 
each containing two grains of orthoform act very happily in some 
cases. A solution of ten grains of menthol in a fluidounce of 
liquid petrolatum, contained in a suitable atomizer, may be 
given to the patient for home treatment, and the throat may be 
sprayed with this remedy several times daily. Dobell's solution 
also may be used in this way. The patient must be urgently 
warned not to swallow his sputum or expectorated matter. 
These liquids swarm with germs and should be received into 



LARYNGEAL INFECTIONS 26 1 

vessels containing strong germicides, e.g., chloride of lime. In- 
stead of handkerchiefs, paper napkins should be used when 
walking or riding. These must be burned while still damp with 
the sputum. 

Syphilitic laryngitis is almost always one of the secondary or 
tertiary manifestations of venereal disease, though a few cases of 
chancre of the epiglottis have been reported. It gives rise to 
mucous patches, gummata and ulcers, appearing in the order 
named, unless the morbid process be arrested. These local 
features bear to the constitutional disease a relation similar to 
that held by the throat lesions of tuberculosis to its effect upon 
the whole body, with this difference, that in tuberculosis the 
laryngeal affection is mostly subordinate to that of the lungs, 
while in syphilis the throat is the chief local focus and by its 
changing symptoms we form our judgment regarding the ad- 
vance or repulse of the constitutional malady. In view of this 
fact the course of treatment, general as well as local, is mainly 
directed by the laryngeal conditions as they are observed from 
day to day. 

Syphilis is caused by the spirocheta pallida, one of the smallest 
known micro-organisms. Lenses of very high power used by a 
skilful microscopist are necessary for the discovery of this germ 
and repeated examinations are often required to obtain ocular 
proof of its presence. Fortunately, the Wassermann and 
Noguchi reactions give evidence of the existence of the germs, 
even when they elude the microscopic test. A perfect demon- 
stration is obtained when the ocular and chemical findings are 
mutually corroborative. When the diagnosis is open to doubt, 
the physician is wise to invoke the aid of the laboratory so that 
his opinion may be reinforced by all procurable evidence. 1 

1 The question of syphilitic infection concerns not only pathology and thera- 
peutics but has a bearing on many other relations, domestic, social, even 
political. The Emperor Frederick, father of the present ruler of Germany, 
died of a throat disease whose nature caused an acrimonious dispute between his 
English and German laryngologists. The controversy grew very bitter, was 
taken up by journals in both countries and produced ill effects of a permanent 
ch aracter. 



262 NOSE, THROAT AND EAR 

Mucous patches are produced by the necrosis of the epi- 
thelial layer of the mucosa in clearly circumscribed areas. This 
exfoliation leaves a pinkish, vascular spot, tender to the touch, 
but giving little pain. The gummata are round-cell infiltra- 
tions of nodular appearance, occupying either the site of former 
mucous patches, or the intervening spaces. The ulcers are 
produced by retrograde, putrefactive changes in the gummata, 
which soften so that part of their substance becomes a decaying, 
pultaceous mass. This is cast off, leaving an annular depression, 
whose edges are clear cut and commonly, though not uniformly, 
indurated. A scanty exudation of purulent fluid comes from 
the ulcers and there is sometimes bleeding, due to erosion of the 
submucous capillaries. They are not very painful. All these 
lesions occur most frequently upon the anterior half of the larynx, 
while tubercular lesions show a preference for the posterior half. 
The characteristics of syphilitic ulcers just mentioned serve to 
differentiate them from those of tubercular origin, which are 
very shallow, have ill-defined edges and cause intermittent at- 
tacks of severe pain. 

The remedies, par excellence, for syphilis are mercury and 
potassium iodide. Although we may be unable to give a full 
explanation of their mode of antagonizing the disease, their 
therapeutic efficiency is established as firmly as any fact in 
medical science and, to set them aside, in favor of some drug 
whose properties and powers are still in dispute, is to assume a 
very grave responsibility, both moral and legal. Now that the 
pathogenic germ of syphilis is known, we hope that serum ther- 
apy, which has given us the mastery of other destructive 
maladies, may furnish us with an antitoxin which will prove a 
true specific and signalize the victory over this universally 
dreaded disease; but that triumph is not yet won and until it is 
we must continue to employ those remedies whose curative 
powers are attested by world-wide experience through many 
generations. Salvarsan and neosalvarsan have passed through 
the stage of exaggerated popularity, the stage of reactionary 
criticism, and are still upon trial. In view of the many dangers 



LARYNGEAL INFECTIONS 263 

attendant upon their use, dangers which are accentuated by the 
method of intravenous injection upon which the advocates of 
salvarsan insist, these synthetic combinations of arsenic and 
chlorine cannot be regarded as antisyphilitics of general applica- 
bility. I do not advise their use except in cases which prove 
refractory to the mercurials and iodides, or which present some 
positive counter-indication. Occasionally one meets with idio- 
syncrasies, which forbid the administration of mercury and 
iodine, but these instances are rare. 

Mucous patches should be cleansed by the spray of Dobell's 
solution, frequently employed. Some of them will heal without 
further treatment under the influence of mercurialization of the 
system. When granulation is tardy, silver nitrate should be 
applied to each patch with a cotton-tipped probang wet with 
a twelve and a half per cent, solution: sixty grains to the 
fluidounce. The occurrence of gummata and ulcers is an indi- 
cation for speedily bringing the system under the influence of 
mercury, either by inunction with the unguentum hydrargyri or 
by hypodermic injections of a solution of hydrargyri bichlo- 
ridum. Potassium iodide also should be exhibited in doses of 
from ten to thirty grains. Topically there should be thorough 
cleansing with the spray of Dobell's solution and then cauteriza- 
tion with the twelve and a half per cent, solution of silver ni- 
trate, followed by insufflation with iodoform powder, or one of 
its substitutes. 

(Edema, which sometimes occurs, must be treated as 
when of nonsyphilitic origin. If it cannot be reduced by 
astringents, or scarification, recourse must be had to trache- 
otomy, or to intubation, which will be subsequently considered. 
The healing of large ulcers may give rise to much cicatricial 
tissue, whose eventual contraction causes stenosis of the larynx. 
This unfortunate sequel is treated by stretching the scar tissue 
with Schroetter's laryngeal tubes which are graded in sizes of 
progressively increasing diameter. The constricting, cica- 
tricial band may require division with a blunt-pointed bistoury. 
The good effect of this incision is liable to be counteracted by 



264 XOSE, THROAT AND EAR 

the union of the separated segments, hence it is better, if the 
structural conditions permit, to remove a small V-shaped 
wedge of the band, so that the raw surfaces will heal by granu- 
lation without coming together. If this procedure is successful, 
it produces a permanent enlargement of the passageway, 
decidedly relieving the symptoms caused by the stenosis. 

As diphtheria has already been considered in the chapters 
dealing with the nose and the faucial tonsils, it is necessary 
here only to advert to some special features of its laryngeal 
manifestations. In character the pseudo-membrane which 
forms in the larynx is identical with that observed in the nose 
and upon the tonsils, but in quantity it is often less. The 
coincident inflammatory symptoms and the involvement of the 
lymphatics are often less marked than in the nasal type. The 
great fatality of laryngeal diphtheria arises, not from the viru- 
lence of the disease, but solely from the closure of the glottis 
and the consequent suffocation. To avert this danger becomes 
the paramount object of treatment, as soon as the larynx is 
attacked. A hypodermic injection of antitoxin must be given 
as promptly as possible and while that remedy is bringing the 
disease under control, topical medication should be used and 
preparations made for intubation, so that it may be performed 
as soon as dyspnoea grows serious. If the patient is vigorous, 
free vomiting should be induced by a full dose of the wine or 
syrup of ipecac. In feeble, exhausted children, the strain of 
emesis may countervail its benefits. Two remedies have a 
well-established reputation for retarding the extension of the 
false membrane and rendering it less adherent and hence 
easier to dislodge: these are steam and mercurial vapor. A 
simple contrivance for their administration is made by having 
a bar of wood extend horizontally over the bed or crib, at the 
height of three feet above the child's head. This bar is about 
an inch in diameter (part of a broom handle can be used) and 
one end is firmly attached to a window frame, or to a block 
screwed, or nailed, to the wall; at the other end is fastened the 
center of a small sheet, which is draped over the child in the 



- LARYNGEAL INFECTIONS 265 

form of a tent, the lower margins being secured to the bed by 
safety pins. Two upright slits are cut in this "tent" so as to 
form a curtain door, which is rolled up and pinned, leaving an 
opening large enough for any manipulations the nurse may wish 
to make. 

A teakettle half filled with water is heated over a gas or oil 
flame until the steam comes off freely at the spout, and this 
steam is conducted into the tent through a rubber tube, whose 
free end is held as near the child's face as may be done without 
the risk of scalding. In this way the air within the canopy is 
soon saturated with warm moisture which is inhaled at every 
breath. The mercurial vapor is procured by putting ten 
grains of calomel upon a small shovel, or an iron spoon, and 
heating it over the flame until it begins to volatilize, when it is 
held within the tent as long as the fumes continue to rise. 
The atmosphere is thus impregnated with mercury in the form 
of vapor that produces the local effect of the medicine, often 
with good results. 

In some mild cases, these measures prove sufficient to prevent 
obstruction of the glottis; but if the cyanosis continues and 
the dyspnoea is not relieved, intubation must be performed 
without delay. This very valuable operation is attended 
with one serious risk against which there is no absolute safe- 
guard, that is the danger of pushing some of the false membrane 
down into the trachea, where it will act as a plug, causing 
speedy suffocation. It is plain that this accident is more 
likely to occur if the membrane is loosely attached, or if part 
of it is exfoliated, than if it be firmly adherent throughout its 
extent; for in the first case, the tube may push before it a 
separating fragment, while, in the second, the tube in its 
descent will glide over the surface of the firmly held membrane. 
We can rarely determine just what condition the membrane is 
in because a good visual inspection cannot be obtained. The 
laryngoscope cannot be satisfactorily used with young children, 
especially when they are struggling in pain and fear; hence our 
knowledge of the location and constitution of the pseudo-mem- 



266 NOSE, THROAT AND EAR 

brane is necessarily imperfect. The only available precaution 
against impelling a fragment into the trachea is to wind a 
narrow strip of gauze around the tip of a curved applicator so 
that the free edge is in loose concentric layers, while the other 
margin is tied to the instrument, then to carry this broom of 
gauze down to the larynx and move it gently from side to side. 
If there are any loose fragments of membrane, they are apt to 
be entangled by the fringe-like edge of the pledget and to 
come away when it is withdrawn. In spite of our best efforts, 
the risk of occluding the trachea remains, and before intubation 
is performed all preparations should be made for doing a 
tracheotomy on a moment's warning, if we find the passage 
closed. 

The intubation tubes invented by Edward O'Dwyer, by 
whom this operation was introduced, are seven in number, the 
three smaller ones being designed for infants of one, two and 
three years and the other four intended for those whose ages are 
four to live, six to seven, eight to nine, and ten to twelve, 
respectively. A tube consists of a hard rubber sheath of 
cylindroid shape somewhat enlarged in the middle to promote 
its retention in the larynx. The upper end has a flange, 
designed to rest upon the posterior laryngeal wall next to 
the oesophagus; at this end also there is a thread hole 
through which a three-foot piece of floss silk is passed and 
its ends knotted together to furnish a retractor. A metal 
bar called the obturator fits inside the hard rubber sheath; 
its lower end is smoothly rounded and by projecting 
slightly beyond the inclosing sheath, it facilitates passage 
through the larynx, while its upper end is cut with a screw 
thread which fits a corresponding screw in the instrument 
termed the introducer. This consists of a steel handle and a 
shank bent at nearly a right angle and having at its distal end 
a screw thread corresponding with that upon the obturator. 
Parallel with the shank there is a fork which can be thrust 
forward by a knob on the handle and which, when so advanced, 
pushes against the hard rubber tube, thus withdrawing the 



LARYNGEAL INFECTIONS 267 

obturator from its interior. Another necessary implement is 
the extractor. It has a metal handle and a curved shank con- 
sisting of two coaptated arms working on a pivot and terminating 
in jaws whose holding surface is made by indentations upon 
their outside. When the hard rubber tube is to be withdrawn, 
the closed jaws are inserted into the upper end then, by pressure 
on a lever, the jaws are opened, their exterior dentations take 
hold of the tube upon its inner surface, and bring it out together 
with the extractor. 

When all preparations for the intubation are complete, the 
child is wrapped in a sheet extending from the neck to the 
ankles whose folds confine the arms to the side and hold the 
legs in apposition. He is then seated on the left knee of the 
nurse, his limbs extending downward between hers and his 
head resting upon her left shoulder. This is the preliminary 
posture, but at the moment of introducing the tube, the 
patient's head should be lifted by an assistant and sustained 
by the palms of the hands applied over the ears, since in this 
position the intrapharyngeal space reaches its greatest di- 
mensions. The surgeon stands facing the patient and adjusts 
the mouth gag whose handles extend across the left cheek and 
are steadied by the nurse. He then inserts the forefinger of his 
left hand into the pharynx, following the median line. Using 
this finger as a guide he introduces the tube. Its first position 
is flat upon the middle of the tongue, the curve of the introducer 
bending over the center of the lower jaw and the handle, 
grasped by the surgeon's right hand, extending downward 
parallel to the child's sternum. The silk thread has been 
secured to the little finger of the operator's right hand and is 
thus kept free from entanglement. 

The left forefinger now advances to the larynx and finds 
the nodular eminences on the top of the arytenoid cartilage; it 
then lifts the tip of the epiglottis and doubles it over toward the 
root of the tongue (Fig. 93). At the same moment the handle 
of the introducer is raised, causing the tube to advance across 
the epiglottis bringing the end of the obturator directly above 



>68 



XOSE, THROAT AND EAR 



the glottis. The guiding finger now returns to the arytenoid 
eminences to prevent the obturator from passing beyond them 




Fig. 93. — Intubation of the larynx. The forefinger of the operator's left hand 
lifts the tip of the epiglottis and bends it over upon the root of the tongue. 




Fig. 94. — Intubation. The introducer is horizontal in the mouth and the tube 
occupies the lumen of the larynx, the flange resting upon the posterior wall. 

and entering the oesophagus. Carefully and with very little 
force, the handle is raised, until it has circumscribed an arc of 
ninety degrees and projects from the mouth in a horizontal 



LARYNGEAL INFECTIONS 269 

line (Fig. 94). At this moment, if all has gone well, the tube 
should occupy the lumen of the larynx, with the flange at its 
top resting upon the arytenoid cartilage. Every step so far 
may have been right, but the peril is great, for the tube in the 
larynx is a closed tube and the air is cut off. Therefore, as 
quickly as possible, the guiding finger is brought to the flange 
to hold the tube in position, the knob on the introducer is 
pushed toward the fork and the obturator withdrawn (Fig. 95) . 
Restoration of free breathing is generally signalized by a few 




Fig. 95. — Intubation. The obturator is released from the tube and with- 
drawn, leaving the passage open for respiration. As a precuation, the silk thread 
is, for a time, left attached. 

short coughs which are speedily followed by amelioration of all 
the symptoms; the cyanosis disappears; the depressions above 
and below the clavicles grow less and less and soon the child 
falls into a deep sleep. If possible, the surgeon should remain 
for an hour after performing intubation, to make sure that all 
details have received proper attention and that the plan of sub- 
sequent treatment is well understood. The purpose of the silk 
thread is to recover the tube, should it have passed into the oeso- 
phagus; when there is certainty that it occupies its proper posi- 
tion in the larynx, the thread should be removed by cutting it 



270 



NOSE, THROAT AND EAR 



near the knot and then making traction upon the knotted 
end. 

The success of intubation depends largely upon working in 
the median line which is the best road to take, and also on 
observing the arytenoid eminences as a demarcation to avoid 
passing into the oesophagus. If a mistake occurs, the only 
thing to do is to withdraw the tube and try again, but the situ- 
ation is peculiarly trying, because of the peril involved in 
delay. Sometimes the tube becomes loose and is coughed 




Fig. 96. — -Intubation. When the tube is no longer needed, it is withdrawn 
with the extractor guided into the orifice by the forefinger of the operator's left 
hand. 



up. Otherwise it is left in place for from three to seven days, 
when the pseudo-membrane has been exfoliated. It is then 
removed with the extractor, a procedure depicted in Fig. 96. 
While a child is wearing a tube, its feeding is a matter of 
serious concern. The escape of solid or liquid food into the 
trachea may cause such violent coughing that the tube may be 
expelled and the patient suffocate before any one can be pro- 
cured who has skill to reinsert it. One way to obviate the 
danger is to rely exclusively on milk and to give it through a 
soft catheter which enters the nose and passes thence through 



LARYNGEAL INFECTIONS 271 

the pharynx into the oesophagus, or even the stomach. Another 
plan is to give the patient liquid food in small portions while 
he lies on his back with the head lower than the chest, so that 
gravity may act to prevent anything entering the larynx. A 
third method is to depend wholly upon rectal feeding with 
predigested aliments, and as the period, when these extra- 
ordinary precautions must be taken, is only a few days, at 
most, it would seem that rectal alimentation which gives 
perfect security against both solids and liquids invading the 
larynx, is a rational solution of the problem. It is not an 
efficient method of sustaining nutrition, but is fairly satis- 
factory as a temporary expedient. 



CHAPTER XXIV 

LARYNGEAL NEOPLASMS 

New growths in the larynx, like those occurring elsewhere, 
are classified as benign or malignant. Those of the first class 
include papillomata, fibromata, lipomata, angiomata, chondro- 
mata, adenomata, cysts and polypi. In this country papillo- 
mata (Fig. 97), occur so frequently as to outnumber all the 
others combined. Their structure shows a mesh of connective 
tissue filled by the infiltration of round cells and traversed by 




Fig. 97. — Papilloma of the larynx; a multiple growth almost completely cover- 
ing the vocal cords. 

minute blood vessels. They are covered by squamous epithe- 
lium of unusual thickness whose surface presents a rough, warty 
appearance and a pale, pinkish hue. They may be single or 
multiple and may be attached to the mucous membrane by 
either a broad base or a slender pedicle. These growths most 
commonly spring from the vocal cords, the ventricular bands 
and the epiglottis, and some of them are found in the sub- 
glottic region. 

Next in clinical importance are the polypi: soft, pale, pedun- 
culated tumors, very similar to the nasal polypi already de- 



LARYNGEAL NEOPLASMS 273 

scribed, but usually of firmer structure on account of a larger 
proportion of connective tissue. They very often spring from 
the vocal cords, being attached to either their upper or lower 
surface. Cysts, which sometimes attain a considerable size, 
are enlarged and modified mucous glands whose orifices have 
been occluded and which have in consequence been distended by 
the retained secretion. They are of spheroidal shape and have 
broad bases. 

The other varieties of benign neoplasms are comparatively 
rare. In company with the three just mentioned, they have 
certain common characteristics. They are nearly painless and 
grow slowly, often existing for months without causing any 
marked symptoms. When symptoms do occur, one of the 
first is impairment of the voice which becomes weak or hoarse 
and may be (at a later stage) suppressed. A curious vocal 
phenomenon is sometimes observed. After being quite hoarse 
for weeks, the voice suddenly regains its normal character and 
the patient supposes himself well, till after a variable time the 
hoarseness returns as suddenly as it disappeared. The ex- 
planation is that a pedunculated tumor, usually a polypus, was 
wedged between the vocal cords near either their front or rear 
extremity and impaired phonation until, by some expulsive 
rush of air, its bulbous part was thrown on top of the cords, 
leaving the glottis free from everything except the slender pedicle; 
this movement restored the voice and it remained normal 
until some strong inspiration carried the pendulous bulb back 
to its old position and the symptoms of obstruction returned. 

When a neoplasm becomes large, it impairs respiration and 
dyspnoea is added to the vocal symptoms, especially : when 
the growth is sub-glottic and is hence in a constricted position. 
There is also some cough, but very little expectoration and no 
haemorrhage. Dysphagia is a symptom when the tumor is at 
the posterior part of the larynx near the oesophagus. 

In the treatment of multiple papillomata of small size, 
good results have followed the topical use of alcohol. The 
remedy, undiluted, is put into an atomizer with a long delivery 
18 



274 NOSE, THROAT AND EAR 

tube and the spray thrown into the pharynx for several minutes, 
the procedure being repeated four or five times a day. Con- 
striction of the vessels and ischnemia follow this treatment and 
the papillomata gradually shrink until nothing is left but the 
scale-like remains of the warty epithelium; these, too, finally 
separate from the restored mucous membrane and are coughed 
up. The larger papillomata and the neoplasms of other 
varieties require surgical treatment and can be removed either 
by the intralaryngeal method or through an external incision 
in the median line of the throat. The operation from the 
inside is done in two ways. The technique of the first is to 
render the interior of the larynx anaesthetic by swabbing it 
twice with a twenty per cent, solution of cocaine upon a cotton- 
wound applicator, and then cutting away the growth with a 
curette or forceps, the operator being guided by an image 
reflected in the laryngeal mirror which is constantly kept in 
position, being held by the surgeon's left hand. 

A great part of the instruction concerning diseases of the 
larynx is imparted by means of figures and colored plates, 
hence it is unfortunate that nearly all our text books print these 
pictures without correcting the lateral reversal of the image 
caused by the laryngoscope, as by other mirrors. For ex- 
ample, in a recently published text book, written by a professor 
of high standing, there is a drawing clearly showing a polyp 
springing from the left vocal cord, yet the printed description, 
immediately below, says the polyp is on the right vocal cord, and 
similar errors occur frequently in this work. Contradictions of 
this sort are very confusing to a student and it is strange that 
they remain uncorrected, in edition after edition of works 
designed for use as text books. 

The second way of operating induces anaesthesia, as has 
been already described, but dispenses with the laryngeal 
mirror and employs the tube devised by Chevalier Jackson 
which has the great advantage that there is direct illumination 
of the field of operation instead of its reflexion in a mirror. 
This instrument is a strong metal tube an inch in diameter 



LARYNGEAL NEOPLASMS 



275 



bent twice at right angles, so that the proximal section serves 
as a handle grasped by the surgeon's left hand. The distal 
section holds a vertical position from the lips to the top of the 
larynx; at its lower end is a flange by which the epiglottis is 
engaged and bent toward the root of the tongue, and a little 
above this is fastened a very small incandescent lamp. Electric 
conductors pass from this lamp up through this third section of 
the tube and at its end make connection with the rheophores 
of a battery. When the circuit is closed the top of the larynx 
is brightly lighted and the surgeon operates by passing his 




Fig. 98. — Misleading schema of direct laryngoscopy and bronchoscopy. 
{Jackson.) 



instruments through the tube. Difficulties were experienced 
by some surgeons in using the tube invented by Jackson and he 
was convinced that they arose from faulty technique, especially 
in regard to the posture of the patient. At the meeting of the 
American Medical Association in 1909, he exhibited diagrams 
of the correct and incorrect positions. These are reproduced 
in Fig. 98 and Fig. 99. 

Neoplasms may be ablated with forceps whose jaws are ser- 
rated, or have cutting edges. Jaws ending in ring-shaped 
curettes are sometimes best. Some growths are most easily 
grasped by blades which open laterally, others by those having 



276 NOSE, THROAT AND EAR 

an anterior-posterior motion. The usual mechanisms in which 
the blades are held together by a pivot which acts as a fulcrum 
answers the purpose in many cases, but where there is very 
little room we may best use an instrument with a curved, 
hollow shank at the distal end of which the jaws protrude and 
are opened and closed by the movement of a sliding knob near 
the handle. For work of this kind it seems necessary to have 
a considerable number of instruments, so that a proper selection 
can be made adapted to the peculiarities of each case. 




Fig. 99. — Schema showing correct position of patient and of the instrument in 
relation to the air passages. The instrument should touch the upper teeth very 
gently if at all. (Jackson.) 

In all intralaryngeal operations, especial care must be 
taken to avoid injuring the normal structures, particularly 
the vocal cords, for there is always a possibility of postoperative 
dysphonia, even entire loss of the voice. After a tumor has 
been removed the raw surface at its base should be touched 
with lactic acid. 

External operations are in general to be avoided, but may 
be necessary when neoplasms are so situated in the sub-glottic 
space that they cannot be extirpated from above, and also 
where great dyspnoea creates urgency for immediate clearing 
of the breath-road. After a sufficiently long vertical incision 
has been made in the median line and has penetrated the 



LARYNGEAL NEOPLASMS 277 

anterior wall of the larynx, the tumors are very accessible and 
can be removed without difficulty. As there is considerable 
laceration and the incision is made in structures which cannot 
be kept in a state of absolute rest, the healing process is at- 
tended with risks; accurate apposition of the surfaces is hard 
to secure and there is liability to cicatricial deformity. This, 
however, is not inevitable and in some cases there is com- 
plete recovery with unimpaired phonation. Killian, who 
originated the use of direct illumination in laryngeal examina- 
tions, has introduced within the past three years a modifica- 
tion of this technique, termed "suspension laryngoscopy." 
This procedure employs a speculum of large lumen attached 
to a handle and shank bent at a right angle and supported, 
not by the surgeon's left hand, but by an overhead beam or 
crane to which one end is fastened by a hook or chain. When 
the speculum is passed into the throat, an adjustable mouth- 
gag, with which the instrument is fitted, prevents slipping or 
displacement by the weight of the head. The body of the 
patient rests upon a table or frame whose height is so regu- 
lated that the weight of the head is borne by the speculum 
which by this traction is pressed toward the anterior wall of 
the throat. After these adjustments have been made, the 
other steps of the examination are similar to those taken when 
the speculum is held by the hand. Among the advantages 
claimed for suspension laryngoscopy are that the weight 
borne by the speculum keeps it very close to the front wall 
of the throat, thus bringing into view the anterior commissure 
of the larynx which is often so far forward as to be out of the 
line of vision, and that mechanical suspension greatly facili- 
tates the surgeon's work by releasing his left hand which 
otherwise would be occupied in the constant and wearisome 
task of holding the speculum. Relieved of this, he can em- 
ploy a bimanual technique throughout the operation. 

Malignant neoplasms are found almost entirely in the forms 
of epithelioma and sarcoma, the former being five times as 
prevalent as the latter. They occur in men more frequently 



278 NOSE, THROAT AND EAR 

than in women and, like cancers in adjacent regions, belong 
to the latter decades of life. Their symptomatology differs 
from that of benign tumors in that they are darker in color 
and harder in consistency than most of those, and also grow 
more rapidly, are painful and have a tendency to haemorrhage. 
Symptoms should not be relied on for the differential diagnosis. 
If there be a suspicion of malignancy, a shred of the growth 
should be taken for microscopic examination. Hope of cure 
is limited to small growths in their very early stages, and 
the sole procedure which has a prospect of success is thorough 
extirpation by the external method of operation: a radical 
measure which removes entirely that half of the organ which is 
effected. In advanced cases and where there are malignant 
growths upon other organs, treatment is only palliative. 



CHAPTER XXV 
LARYNGEAL EXTRANEA 

Foreign bodies of many kinds reach the larynx either through 
mental immaturity or, later, through incapacity and care- 
lessness. The proneness of small children to put things in 
their mouths is not a sign of perversity, as some people think, 
but the survival of an infantile practice, based on a very 
good reason. The baby's fingers are weak and fragile, but its 
jaws are relatively strong, its alimentation depends on the 
firmness of their grip without which there would be no suc- 
tion, and the little creature soon learns to hold the objects it 
desires in the strong grasp of the maxillary muscles which are 
much more trustworthy than the feeble and uncertain hands. 
The fact that the mouth is not available as a general receptacle 
and also as a universal tool is a later mental acquisition and 
for a good while the old habit influences the child's actions. 
Once the articles are in the mouth, their passage into the larynx 
may be due to a great variety of accidents. Among older 
persons, the lodgement of extranea in the laryngeal region is 
favored by mental incapacity such as is seen in the insane, 
where it is often conjoined with some anaesthesia of the larynx 
and its surroundings. Intoxication renders the throat tempora- 
rily less sensitive than usual and while this condition lasts 
the drunken man may be unconscious of the presence of foreign 
bodies which have slipped back from the mouth. As soon 
as he becomes sober these extranea signify their presence by 
pain, cough and dyspnoea. The very reprehensible care- 
lessness which allows patients to eat heartily shortly before 
the inhalation of an anaesthetic, is responsible for many acci- 
dents. Vomiting occurs while the patient is relaxed and un- 

279 



280 NOSE, THROAT AND EAR 

conscious and some of the half digested food is apt to enter 
the larynx, even the trachea and bronchi. 1 

Another cause of these accidents is the habit of upholsterers 
to fill their mouths with carpet tacks to be dropped one by- 
one and driven into the floor. It is a most dangerous practice, 
but many workmen with almost incredible stupidity con- 
tinue it, even at the risk of losing their situations in shops 
where it is forbidden. 

Sharp or pointed articles, such as tacks, may lodge in 
different parts of the organ; smooth particles are most fre- 
quently found in the ventricles, where they may remain a 
long time, giving rise to few symptoms until their position is 
accidentally shifted and their presence thus manifested. 
Dyspnoea may not be observed unless the foreign body is 
lodged directly over the glottis and is sufficiently large to 
obstruct half of it; cough is usually present, but it is attended 
with little expectoration, hence a cough of this character, not 
readily explained in other ways, should create suspicion of 
an extraneous object, especially when the patient is a child 
or an adult of feeble mentality. 

The object of treatment is, of course, to remove the foreign 
body, but to this statement must be added the caution that 
efforts for removal must never be made in a way which may 
push the object further down, into a situation where it will 
be much more dangerous, perhaps changing a case of 
partial obstruction into a case of fatal suffocation. There 
is a popular notion that when anyone has a foreign body in 
the throat, he should be slapped violently upon the back, and 
perhaps turned so that his head is lower than any other part 
of the body. Small children are often wholly inverted and 
held suspended by the feet. Of course, there is a chance 
that, in such a posture gravity may cause the extraneum to 
drop into the mouth, but the position is so unnatural that 

1 A surgeon was asked, "What does vomiting during general anaesthesia sig- 
nify?" His reply was both wise and witty, "It is a sign that somebody on 
the hospital force should be discharged." 



LARYNGEAL EXTRANEA 28 1 

it is liable to do much harm and, in adults particularly, it in- 
volves danger of cerebral congestion. Besides this, the foreign 
body may be moved into some situation where it is harder to 
dislodge than it would have been in the locality primarily 
occupied. Often a physician is not called until the members of 
the family have tried many expedients to get rid of the ob- 
structing object and have made the patient's condition de- 
cidedly worse. 

If the dyspnoea is not urgent, a careful examination of 
the larynx should be made under the best illumination the 
circumstances permit. The laryngeal mirror may be used or 
the tubular speculum of the Killian or Jackson pattern, already 
mentioned in the discussion of neoplasms (Chapter XXIV). 
The Jackson tube has the great advantage of furnishing ample 
illumination at the point where it is needed, free from the 
drawbacks incident to reflected light. On the other hand, it 
restricts still more the small space in which we must work. 
If the foreign body cannot be found and the danger of suffo- 
cation increases, or if, when located, it cannot be dislodged, 
and there is risk of it going down the trachea we must per- 
form tracheotomy, and then make the extraction. After the 
offending body has been removed, the tracheal wound may be 
closed at once, provided there has been no laceration except 
the operative incision and no prior trauma of the larynx, but 
if damage, has been done, it is safer to keep a tracheotomy 
tube in place until the danger of swelling of the glottis is 
past. In the more favorable cases, which are also the more 
numerous, the extraneum can be seen and is accessible to 
properly contrived instruments. When this is so, it should 
be grasped with jaws, which will not permit it to slip, and 
carefully withdrawn. There are various types of forceps 
adapted to this procedure. Those whose jaws are opened 
and closed by means of a sliding knob near the handle have the 
advantage of occupying less space than those working on a 
pivot. Tuerck devised an instrument with a handle fitted 
with a sliding knob which controls the posture of whatever 



282 NOSE, THROAT AND EAR 

jaws are attached to the shaft; they may be serrated, fenes- 
trated or of other pattern. The shaft itself is a flexible sheath 
and can be curved to meet the situation of the extranea as the 
jaws are made to suit their character. 

The removal of a foreign body may cause some excoria- 
tion of the laryngeal walls and some bleeding, usually slight. 
Until all discomfort has passed away, the organ should have 
rest from phonation. Just after the operation it should be 
sprayed with a fifty per cent, solution of peroxide of hydrogen, 
and a two per cent, solution of cocaine may be used as a spray 
four or five times during the subsequent twenty-four hours, if 
there is much soreness. After that, spraying with normal salt 
solution three times daily is all that is likely to be required. 



CHAPTER XXVI 
LARYNGEAL NEUROSES 

The nerves of the larynx are the superior laryngeal whose 
function is motor and the inferior, or recurrent laryngeal, 
which conveys motor and also sensory impulses; both have 
their origin in the vagus. In addititon to these cranial nerves, 
there are small filaments given off from the sympathetic. 
The left side of the larynx is more liable to neuroses than the 
right, a fact attributed to the course of the recurrent nerve on 
that side, which on account of its proximity to the aorta, is 
affected by aneurysm of that artery. 

Sensory abnormality may take the form of anaesthesia, 
hyperesthesia or paresthesia. In the first condition, atten- 
tion is directed to the morbid state by the frequency with 
which food and drink "go the wrong road." The patient's 
meals are interrupted by attacks of violent coughing, even 
when the food is unirritating and is eaten slowly. The glottis 
does not close and hence the breath-road is not occluded, as 
it should be during deglutition. In the anaesthesia the muscles 
lack their appropriate nervous stimulus and fail to perform 
their normal function. This symptom is often the only one 
observed, unless there is coincidently present some motor 
neurosis. Laryngeal anaesthesia may be one of the sequels 
of diphtheria; when this is the case, much benefit may be 
expected from the administration of strychnia (strychnia 
sulphate, gr. i ( - , three times daily), as in other forms of 
nerve atony produced by the diphtheritic toxin. This treat- 
ment may be reinforced by faradization, a mild current being 
distributed through the laryngeal region by holding a sponge 
electrode on each side of the throat below the angle of the 
jaw. The current derived from an electromagnetic battery 
should be strong enough to be felt, but without pain, and 

283 



284 NOSE, THROAT AND EAR 

should be continued for ten or twelve minutes, reversing its 
direction each minute. This treatment given daily will usu- 
ally confer all the benefits to be derived from electricity, with- 
out carrying an electrode directly to the larynx. Even where 
the anesthesia is not of diphtheritic origin, the coordinate 
use of strychnia and faradization often renders deglutition more 
normal, but when the cause is some cerebral or medullar lesion 
the laryngeal disorder cannot be expected to disappear until 
that cause has been removed. 

Hyperesthesia is usually due to some irritation in the phar- 
ynx, fauces, or nose; frequently to hypertrophy or varix 
in the lingual tonsil. Its cure depends upon the successful 
treatment of these causal conditions. Paresthesia also has 
mostly a peripheral origin, unless it be subjective. Patients 
complain of various annoying sensations, as of some small 
solid body changing its position from the root of the tongue 
to the lower end of the larynx and vice versa; pricking by pin 
points; hairs stretched across the passageway and sometimes 
heat or cold. These sensations may be due to morbid changes 
in the lingual tonsil and other structures above the larynx, 
but they are generally experienced by persons described by the 
very expressive, though nearly indefinable term, "nervous," 
and we must bear in mind the probablity that many of the 
alleged pains are subjective, and really occur only as manifes- 
tations of some one of the protean forms of hysteria. In so 
far as they are objective, the best treatment is to correct 
whatever is abnormal in the upper air pasages and, even in 
the subjective cases, such measures give a fair hope of success, 
for there is always a chance that physical restoration of an 
organ, or a function, may induce a favorable psychic alteration. 

The motor neuroses may arise from causes which are either 
peripheral or centric, and they occasion muscular spasms (tonic 
or clonic) or paralysis. The larynx has many muscles and, 
as each one may be affected in a sthenic and also asthenic way, 
the possible number of neuroses makes an extended list, but 
as the importance of these contractions and relaxations depends 



LARYNGEAL NEUROSES 285 

upon their influence upon two functions, respiration and phona- 
tion, the majority are of only secondary interest, while those 
having a marked effect upon the breath and the voice deserve 
special attention. 

The arytenoid and crico-arytenoid muscles are the adductors 
of the vocal cords; unilateral spasm of these muscles brings the 
cord upon the affected side to the median line of the glottis and 
affects the quality of the voice, but air passes up and down on 
the other side and there is little embarrassment of respiration: 
when however the spasm is bilateral, the cords are brought into 
contact, the glottis is closed and suffocation becomes imminent; 
a condition which is the characteristic feature of laryngismus 
stridulus, or false croup. This disease has already been fully 
considered in Chapter XXII. I believe that inflammation of the 
catarrhal type is an important and nearly constant factor in this 
disorder and hence it should be classified as one of the varieties 
of laryngitis. Some authors consider it a pure neurosis, on the 
basis of certain cases which lack signs of inflammatory action, 
but those rare cases do not seem sufficient to justify such a 
classification. A difference of opinion in this respect does not 
change our judgment regarding treatment, the method advised 
in Chapter XXII, being founded upon clinical experience and 
having the approval of those holding the neurotic theory, as 
well as those placing the affection among the inflammations. 

The laryngeal crisis of locomotor ataxia, aphonia spastica, 
laryngeal chorea and laryngeal vertigo; all have, as a common 
factor, spasm of the adductor muscles of the vocal cords, 
generally bilateral and, when severe, imperilling life by suffoca- 
tion. The treatment of these conditions depends mainly 
upon the diseases of which they are manifestations, but as 
dyspnoea is the common danger, so it is the common indica- 
tion to relieve constriction of the breath-road; whatever else 
may be done afterward. For defense against suffocation, 
chloroform and the other antispasmodics recommended in 
the discussion of false croup (Chapter XXII) constitute our 
main reliance. If .they fail, tracheotomy must be perfonned. 



2 35 NOSE, THROAT AND EAR 

Paralysis of the adductors of the vocal cords is precisely 
the reverse of the condition above considered. The abductors, 
being left without their normal restriction, pull the cords to- 
ward the sides of the larynx, leaving the glottis wide open. 
Obviously this neurosis does not stop respiration, for the breath- 
road is kept all the time at its greatest width, but the voice is 
affected by failure to approximate the cords and, when both 
sides are affected, there is aphonia. The symptoms are very 
uncertain, as the nerve control over the muscles is apt to be 
intermittent; aphonia may continue for days, even weeks, 
and then a sudden fright or some other intense emotion may 
cause such a strong neural impulse that the patient will cry 
out in natural tones. This restoration of the voice may be 
lasting, or a relapse may come with equal suddenness. Aphonia 
of this type is common among neurotic patients. The dis- 
covery and cure of lesions affecting the air passages and also 
the superior and recurrent larnygeal nerves are a part of the 
treatment; if there be no organic disease, or if one that exists 
can be cured by medical or surgical measures, then there is a 
favorable outlook, if we can improve the innervation of the 
arytenoid and crico-artytenoid muscles by faradization and 
such roborants as strychnia, arsenic and iron. Remembering 
too that some of the symptoms may be subjective, the patient's 
psychic condition has a bearing upon the prognosis which 
will be much improved if her full confidence is gained and if 
she makes a sustained effort to retain any ground which has 
been gained and to avoid whatever has an injurious effect 
either in diet, clothing or occupation, as shown by experience 
during the progress of the affection which is commonly quite 
chronic in its course. 

Paralysis of the abductors has the same mechanical effect 
as spasm of the adductors; the vocal cords are brought to- 
gether with the risk of impeding respiration. The hindrance 
is chiefly to inspiration; the somewhat flabby cords offering 
very little obstruction to the expired air. This condition is 
usually permanent, unless caused by pressure upon a nerve 



LARYNGEAL NEUROSES 



287 



trunk by a removable tumor, or a syphilitic growth amenable 
to treatment. Patients suffering from bilateral paralysis of 
this kind gradually adapt themselves to it, acquiring a toler- 
ance due to habit. They dare not take violent muscular 




Fig. 100. — Paralysis of adductor Fig. ioi. — Paralysis of the right re- 

muscles on both sides, associated current nerve, in a case of stab wound 
with hysterical aphonia. of the neck. 

exercise and are never wholly free from the danger of a suddenly 
developed dyspnoea, imperilling life. 

The forms of paralysis portrayed in Figs. 100, 101 and 102, 
are among those of frequent occurrence and as noted in the 



i 



1 



Fig. 102. — Paralysis of the arytenoid muscle in a case of acute laryngitis. 

titles of the illustrations may be associated with morbid 
conditions of wider scope; such as inflammation or hysteria. 
When existing, these complications have a bearing upon the 
indications for treatment. 



CHAPTER XXVII 
THE EAR : FORM AND FUNCTION 

Otology is almost wholly a development of the last half 
century. Prior to that time the literature of the subject was 
meager and the few medical men who had acquired special 
knowledge and skill were ocular surgeons who devoted the 
bulk of their time to patients suffering from diseases of the 
eye and the remainder to the much smaller number who 
sought ear treatment. In popular estimation, failure of hearing 
was esteemed an inevitable accompaniment of advanced 
age and, when deafness began in the fifth or sixth decade of 
life, it was accounted a sign of somewhat early senility and the 
man "growing hard of hearing" was advised to try an ear 
trumpet and to practice the virtue of resignation. Com- 
paratively few sought help from the medical profession and the 
profession itself had not yet awakened to the great possibilities 
of aural therapeutics. Treatment of the ear, in so far as it 
was a specialty, was in the hands of practitioners termed 
"oculists and aurists," the aurist function being as second- 
ary in fact as in title. This condition continued until the 
time when the specialties were rearranged and, in study and 
practice, the ear was separated from the eye and associated 
with the nose and throat where it naturally belongs. This 
change in classification was a long step in advance and marked 
an epoch in scientific progress, which was also signalized by 
the general adoption of the term, otology, as the proper title 
for this department; a word which previously had been seldom 
used. Under the new conditions, the study of the ear has 
made rapid strides toward that breadth and accuracy which 
are commensurate with its great importance. 

In Chapter I there is a graphic exhibit of the relations to the 
288 



the ear: form and function 289 

breath-road sustained by three accessary organs, performing 
functions intimately associated with respiration; yet having 
separate and distinctive purposes. Of these the olfactory 
nerves, giving rise to the sense of smell, and the larynx, pro- 
ducing the voice, have already been considered. The third 
accessary organ is the ear, which originates the sense of hear- 
ing. The mechanism of this special sense is more complex 
than that of olfaction or phonation. It is not only unique in 
the complicated character of its anatomical and physiological 
features, but it has ramifications extending into diverse fields 
of knowledge; it is the basis of the distinct and highly de- 
veloped science of acoustics and also of music, probably the 
most important, as it is certainly the most ancient of the fine 
arts. 

The study of the ear is rendered difficult by the fact that 
there are many variations in structure both congenital and 
developmental, so that the organ in one individual presents 
features lacking in another. These variations may be slight 
and constitute merely peculiarities, or they may be so marked 
as to be termed anomalies. The peculiarities and even many 
of the anomalies do not interfere with the functions of the 
organ and hence come within the scope of nonpathologic 
deviations from the typical formation. It is important 
to remember the existence of such deviations and to be on 
the watch for them when operating, for the knife edge may be 
close to a nerve or a vascular sinus* whose usual location would 
be at a safe distance, and the danger of such proximity must 
keep the surgeon constantly on his guard. Variations of this 
sort are seldom a primary cause for operation, unless they prove 
disfiguring. By comparing a large number of normally func- 
tionating ears and by noting those features which are most 
frequently present, the anatomists have been enabled to 
present a typical organ, regarded as the perfect, healthy ear, 
and this has been delineated with great skill in drawings 
and models. By studying this type we can secure a clear idea 
regarding this very complex organ and then add a knowledge 
19 



290 NOSE, THROAT AND EAR 

of the variations found in dissection and in observations on 
the living subject. 

The aural structures are so situated upon and within the 
sides of the skull that they naturally comprise three groups, 
termed the external, the middle, and the internal ear. The 
first two perform the function of conduction; the third that of 
perception. Before entering upon anatomical description, we 
must consider a fundamental question which has paramount 
importance, because its answer is the basis of our conception 
of the entire subject and also determines the language to be 
used throughout the discussion of otology. What is hearing? 
The answer to this question must be clear, accurate and di- 
vested of all that is nonessential, if we are to avoid that 
confusion of thought displayed by many who have tried to 
write definitions and descriptions. Probably the best way to 
gain the right idea is to consider what happens when we hear 
a sound. The sensation of hearing, like other sensations, re- 
sults from the excitation of the distal end of an afferent or 
sensory nerve, for functionally the labyrinth is an amplifica- 
tion of the end of the auditory nerve. Something excites the 
labyrinth and the auditory nerve conveys to the brain a per- 
ception called sound. The thing which excites the laby- 
rinth is vibration. It may take different roads to reach the 
internal ear; a vibrating body, like a tuning fork, may be 
held outside the external ear, then the vibratory movements 
are transmitted through the air in the meatus and through 
the structures in the tympanum to the labyrinth; or the fork 
may stand upon the forehead, then the transmission is through 
the skin, subcutaneous tissues and bones of the skull to the 
same terminal point, but till it reaches that point it is always 
vibration and becomes sound only in the perceptive organism 
of the internal ear. We define sound as vibration interpreted 
by the ear. Where there is no ear, there can be no sound; 
waves may beat against a coral reef far out at sea and cause 
powerful vibrations in the air, the water, and the solid reef 
itself, but if there is present no animated creature endowed 



the ear: form and function 291 

with hearing, all the commotion produces no sound. Sound 
originates in sensation which can exist only where there is a 
living, sensory nerve; but vibration exists everywhere, in the 
earth, in the surrounding atmosphere and in the interstellar 
spaces. The vibrations, which the ear interprets as sound are 
comparatively slow movements, transmitted through matter 
in a solid, liquid, or gaseous state. The much more rapid vibra- 
tions which the eye interprets as light, are transmitted through 
the all-pervading ether. 

The afferent nerves distributed through the body are sub- 
ject to "excitation by vibratory movements affecting their 
distal ends, but they are not so highly specialized as the nerves 
of sight and hearing and the perceptions they convey to the 
brain do not translate the causal vibrations into other forms 
of force, but express them as vibrations. How much knowl- 
edge the brain can get from these perceptions is a question 
whose active study is but recent and the methods of investi- 
gation are still tentative, but we already know that while 
the ear alone is the organ of hearing, yet the information hear- 
ing gives the brain is, in some degree, corroborated or corrected 
by the action of the nerves of general sensation. If ideas 
derived from this source can be substituted for the ideas de- 
rived from audition, then there will open before us a thera- 
peutic prospect almost boundless, for defects in hearing will 
be supplied, not by mechanical devices, but by a parallel 
channel of neural transmission through which the vibratory 
cause will finally give rise to the same idea which was pro- 
duced by the uninjured organ of hearing. 1 If this result shall 

1 A great impetus has been given to the study of this subject by the marvelous 
achievements of Helen Keller, who in early childhood suffered the loss of both 
sight and hearing. The girl's mind, imprisoned in total darkness and absolute 
silence, with unflagging persistence sought to establish communication with the 
outside and aided by the faithful devotion of Miss Sullivan, her teacher, at- 
tained success. The olfactory and gustatory nerves gave assistance, but on 
account of their specialization, they could supply perceptions only in the scope 
of smell and taste, for all else the only resource was the afferent nerves which take 
cognizance of vibrations and transmit to the brain vibratory perceptions. The 
language of vibrations was the only means of communication between the girl's 



292 NOSE, THROAT AND EAR 

be attained, it will be an even greater therapeutic triumph 
than the saving of a limb whose main artery becomes occluded, 
by promoting anastomotic circulation until the collateral 
vessels develop into adequate substitutes. 

The external ear includes all the auditory structures outside 
of the membrana tympani, or drum-head. Its first part pro- 
jects from the side of the head, between the articulation of 
the lower jaw and the mastoid portion of the temporal bone, 
and is composed of a thin layer of cartilage whose surface is 
corrugated by large elevations and depressions. This, being 
outside the skull, is the visible section of the organ and is 
called "the ear" in common, colloquial language, while in 
anatomical descriptions it is termed the auricle or pinna. 
Its natural size is shown in Fig. 103. Nearly all the cartilagi- 
nous border is curled upon itself in a direction away from the 
head, and this inflected edge is called the helix. Its con- 
tinuity is broken in two places: at the bottom, where it is re- 
placed by a pendent pouch of skin filled with connective tissue 
and fat, named the lobe, and just above this on the front, 
where there is a conical eminence, the tragus, on the plane of 
the zygoma. Directly opposite the tragus is a smaller pro- 
jection, the antitragus, and between these is the beginning of 
the external auditory meatus. The antihelix is a bifurcated 
ridge separated from the helix by a groove and having at its 
bifurcation the triangular fossa; below this and terminating 
in the meatus is a deeper concavity, called the concha. On 

mind and the world— a poor medium it seems to us in the light of the slight use 
we make of it — but by this slender bridge the chasm was spanned, intercourse 
was established, knowledge of many kinds acquired and finally a course taken at 
Harvard University and its successful completion attested by the conferring 
of a degree. These nearly incredible facts have proved that the nerves of general 
sensation possess powers and possibilities which have remained unrecognized 
until the present time, and men are now seeking for a practicable method to 
utilize these powers and to make these nerves serve as substitutes for the nerves 
of the special senses, when they are disabled. The outlook is full of promise, 
particularly for those cases where audition is injured, but not destroyed, and 
where the internal ear may be so reinforced by the perceptions of afferent nerves 
that the combined actions will produce a nearly normal result. 



the ear: form and function 



293 



the posterior or mastoid side of the auricle there is a con- 
spicuous convexity which touches the convexity of the concha 
and then sinks to the level of the surrounding skin, the two 
dermal surfaces, diverging from the separating groove, being 
usually in contact. The auricle is attached to the side of the 
head by the integument and also by two ligaments, the anterior 
connecting it with the zygomatic process and the posterior 



Crura of anthelix 



Crus of tie helix- 
Anterior incisure- 



Supratragic tubercle 

Tragus 

Intertragic incisure 




Helix 

Auricular tubercle 

Triangular fossa 
Scapha 



Cymba 



\ Concha 



Cavum j 
Anthelix 
Posterior auricular sulcus 

Helix 



Anti tragus 



Lobule- 



r 



Fig. 103. — The auricle, or visible part of the ear. (Morris.) 

joining the convex cartilage behind the concha with the lower 
part of the mastoid. The cartilage of the auricle is covered 
in some parts by strands of connective tissue and by a net- 
work of vascular and lymphatic vessels, all being enveloped in 
the dermic and epidermic layers of the skin, which in most 
individuals is rather thin; sebaceous and sweat glands are 
numerous in the concha. The muscles consist of striated fibers 
of slight strength; the superior auricular draws the auricle 
upward, the anterior draws it forward and the posterior 
draws it backward, but in many persons these muscles exert 
so little power that the auricle is stationary unless acted on by 



294 NOSE, THROAT AND EAR 

extraneous forces; a few individuals possess extensive muscular 
control, similar to that exercised by many of the lower animals. 
The temporal branch of the trigeminus and the auricular 
branch of the vagus are the sensory nerves of the auricle and 
the external meatus. The arteries are branches given off 
by the temporal and external carotid; the veins unite in a 
single trunk, which enters the temporal vein. 

The external auditory meatus is a canal extending from 
the concha to the membrana tympani. Its entire length, in 
the adult, is nearly an inch and a quarter, about half an inch 
being taken up by the external or cartilaginous section, which 
structurally is a continuation of the auricle, the recess of the 
concha assuming the shape of an elliptical orifice with its long- 
•est diameter vertical and gradually changing to a horizontal 
position in a deeper section of the canal. From this entrance 
the direction is forward and inward and then downward, at 
an obtuse angle, where the cartilaginous section joins the other 
portion. The first part of the meatus is not completely in- 
closed by cartilage; the tubular wall exhibits fissures which 
are filled by fibrous tissue. Its interior is lined by skin con- 
tinuous with that of the auricle, and in this are imbedded the 
usual cutaneous glands, with the addition of the ceruminous 
glands which exist in this locality only. They are tubules 
which by convolution take a spherical shape, the free end act- 
ing as an orifice for secreting a peculiar brownish-yellow 
substance, the cerumen or ear-wax. The breaks in the car- 
tilaginous cylinder, fissures of Santorini, are transverse to 
the course of the canal and render it flexible. They are im- 
portant pathologically, because the fibrous tissue with which 
they are filled is less resistant than cartilage and permits 
infections to enter the canal from the surrounding tissues 
and also to pass from within outward. 

The second portion of the canal is somewhat longer than 
the- first, measuring about three-fourths of an inch; it is also 
narrower. Its interior is lined with a very thin, closely adherent 
skin which becomes continuous with the membrana tympani, 



the ear: form and function 



29s 



and it is inclosed by a wall of bone developed during infancy 
from an osseous ring which terminated the canal during fcetal 
life; a vestige of this antenatal condition remains in the 
narrow groove, sulcus tympanicus, in which the drum mem- 
brane is inserted. The structure of the meatus in both its 
sections and its close proximity to very delicate organs render 



SHRAPNELL'S MEMBRANE 



SPINA TVMPANI 
POSTERIOR 



SPINA TYMPANI 
MAJOR 



SHORT PROCESS MALLEUS 



POSTERIOR FOLD 
OF MEMBRANE 



MANUBRIUM 




ANNULUS 
TYMPANICUS 



DRUM H EAD 

Fig. 104. — The left drum-head viewed from the outside. (Knight and Bryant.) 



it a passageway that will not bear rough handling. Harsh 
and hasty instrumentation may work much injury and will be 
avoided by the careful surgeon. 

The middle ear consists of the tympanum, the drum-head, 
the ossicles, the attached ligaments and muscles, the antrum and 
the mastoid sinuses. The Eustachian tube also is most appro- 
priately included in anatomical descriptions, because of its con- 



296 NOSE, THROAT AND EAR 

nection with these structures. The tympanum, or drum, so 
named on account of its form, is a cavity in the petrous, or hard, 
portion of the temporal bone. The drum-head (Fig. 104) is 
nearly circular, but the space beyond this is an irregular quad- 
rilateral, whose longest diameter, in the adult, is between one- 
half and three-fourths of an inch, while the short diameter from 
the drum-head inward is one-sixth of an inch. All of the wall 
which surrounds the cavity is osseous and belongs to the 
temporal bone; it has no natural segmentation, but for con- 
venience there is an artificial division into roof, floor, anterior 
part and posterior part. The roof is an arch separating the 
tympanum from the cranial cavity; the space under this is 
called the attic or vault and the larger cavity below is termed 
the atrium. A lamella of irregular surface constitutes the 
floor which aids in forming the carotid canal; both roof and 
floor are without orifices. The anterior part of the wall has 
an orifice for the upper end of the Eustachian tube and through 
the posterior passes the inlet to the mastoid sinuses, an open- 
ing of great importance in its pathological relations. The 
partition inclosing the tympanum on the inner side is pene- 
trated by the fenestra ovalis, an elliptical aperture one-eighth 
of an inch long which leads into the vestibule of the laby- 
rinth, and by the fenestra rotunda, a circular aperture closed 
by an elastic membrane, which responds to movements of 
lymph within the labyrinth. Above the oval window is the 
Fallopian canal, giving passage to the facial nerve. 

The outer partition, dividing the middle ear from the ex- 
ternal auditory meatus, comprises the membrana tympani, 
the annulus tympanicus, the membrana flaccida and the 
scutum. Of the three layers entering into the composition 
of the membrana tympani, the one in the middle is the most 
important; it consists of fibers disposed in two strata, in one of 
which the arrangement is circular, in the other radiating. 
Over this central characteristic layer the other membranes 
are reflected, the skin, being a continuation of the integument 
of the meatus, covering the outer surface, and the mucous mem- 



the ear: form and function 297 

brane, projected from the lining of the tympanitic cavity, 
covering the inner surface. At the upper part there is a 
notch, where this fibrous layer is wanting, and here the con- 
joined skin and mucous membrane fill in the vacancy with 
what has been termed the membrana flaccida, because it is 
thin and relaxed. At this point there is frequently found a 
minute orifice, the foramen of Rivinius. It does not lessen 
functional power, and it is an unsettled question whether this 
opening is congenital or of traumatic origin. The center of 
the membrana tympani moves outward or inward in accord- 
ance with the presence of positive or negative air pressure in 
the middle ear; when at rest, it is somewhat retracted so 
that a slight concavity is presented toward the meatus. In 
color the membrane is pearly grey and, when normal, trans- 
lucent, so that the malleus, which is imbedded on the inner 
side, shows through; the short process of this bone, which 
appears as a yellow spot near the upper margin, is one of our 
chief landmarks in making examinations of the membrana 
tympani. Another conspicuous feature is a luminous triangle, 
whose apex is near the center of the membrane and which 
extends downward and forward nearly to the circumference. 

The ossicles of the middle ear are named malleus, incus and 
stapes from a supposed resemblance to a mallet, anvil and 
stirrup. In the third case there is an actual likeness, in the 
others it is fanciful. From the position of the short process of 
the mallet, its handle extends to the center of the membrane, a 
point called the umbo. The malleus articulates with the incus 
and this bone with the stapes, whose base fits into the oval 
window at the entrance of the labyrinth. By this means the 
ossicles establish a chain for the transmission of vibrations from 
the drum-head to the internal ear which interprets these vi- 
brations as sound. A collateral road for transmission exists 
in the air inclosed in the tympanum, but this does not convey 
impulses with the same measure of force. The inner aspect 
of the membrana tympani of the left ear is depicted in 
Fig. 105. 



298 NOSE, THROAT AND EAR 

The Eustachian tube, beginning by an orifice in the anterior 
wall of the tympanum, takes a course downward with an in- 
clination toward the median line, until it terminates in an 
aperture on the side of the naso-pharynx, at the level of the 
posterior nasal orifice. Its upper third, half an inch long, 
has an osseous wall; the other two-thirds are inclosed by 
cartilage. The narrowest part of the tube is the junction of 
the bony and cartilaginous sections, and this is termed the 
isthmus. The interior is throughout lined by mucous mem- 
brane continuous with that of the naso-pharynx and, like it, 




Fig. 105. — The outer wall of the middle ear (left side) viewed from the tym- 
panic cavity; showing inner surface of drum-head, malleus, incus, tensor tympani 
muscle and chorda tympani nerve. 

covered by a ciliated epithelium. A layer of adenoid tissue is 
found beneath the mucous membrane in the cartilaginous 
portion, but this does not extend above the isthmus. The 
Eustachian tube is generally closed, but in swallowing and 
yawning the edges of the lower orifice are separated by action 
of the levator and tensor palati muscles and leave an ellipti- 
form aperture. Even when these edges are in contact, air and 
liquids entering at the tympanic extremity readily pass down 
to the throat, and the tube serves to drain and ventilate the 
middle ear. 

The mastoid sinuses are irregular cavities in the interior 



the ear: form and function 



299 



of this portion of the temporal bone, communicating with each 
other and connected with the tympanum by the antrum on 
its posterior side. They are lined with a thin mucous membrane 
having a squamous epithelium. 

The internal ear, of which an enlarged representation is 
given in Fig. 106, is a very complex and delicate mechanism. 
Its function is acoustic perception, or the interpretation of 




Fig. 106. — The labyrinth Viewed from the outer side. {Knight and Bryant.) 
a, Superior semicircular canal; b, posterior semicircular canal; c, external semi- 
circular canal; d, cochlea; e, vestibule; /, sacculus and macula acustica sacculi; 
h, utriculus and macula acustica utriculi; i, Ductus endolymphaticus; /, ampulla 
of superior semicircular canal and crista acustica; m, ampulla of external semi- 
circular canal and crista acustica; n, ampulla of posterior semicircular canal 
and crista acustica; 0, round window; p, oval window; s, scala media and papilla 
acustica; I, ductus perilymphaticus. 

vibratory impulses as sounds, and it comprises the laby- 
rinth, both osseous and membranous, the internal auditory 
meatus and the auditory nerve. The semicircular canals are 
included in the anatomical description because their structural 
connection with these bodies is so intimate, although the belief 
long held that they played a part in audition is now generally 
given up and they are thought to indicate the stations and 
movements of the body and the three dimensions of space. 



3<X> NOSE, THROAT AND EAR 

The labyrinth begins at the oval window of the tympanum 
and contains the vestibule, the cochlea and the semicircular 
canals. Though imbedded in the petrous portion of the 
temporal bone, it has an osseous envelope of its own which at 
birth can readily be separated from the surrounding bone, 
although later the two coalesce. The vestibule is an ovoid 
cavity between the tympanum and the internal auditory 
meatus; at its top is found the superior cribriform spot and on 
its anterior wall the middle cribriform spot; these spots are 
pierced by a group of minute foramina leading into the 
internal auditory meatus; close to this is the terminus of the 
cochlear passage termed the vestibular scala. 

The semicircular canals, designated superior, posterior and 
inferior, are so situated that their surfaces would lie parallel 
to three faces of a cube, viz., the base and two sides meeting at 
right angles. Each of these canals has one expanded end, 
the ampulla, which enters the vestibule; two of the other ends 
unite and then take the same course, while the third enters 
separately. There are thus five orifices connecting these 
canals with the vestibule. Inside of the vestibule and the 
semicircular canals is a group of membranous structures, com- 
prising three tubes, fitting upon the inside of the semicircular 
canals, and two pouches, located within the vestibule and 
named the spherical saccule and the elliptical saccule, or 
utriculus. These delicate structures and also the mem- 
branous cochlea are surrounded by a serous liquid called the 
perilymph which intervenes between them and the osseous walls 
by which they are enveloped. In each saccule is a minute body 
composed of crystals of calcium carbonate and termed an otolith. 
These ear-stones perform some necessary functions, as is implied 
by their presence in connection with the auditory apparatus of 
most of the lower animals, even those lacking many parts of the 
internal ear, as seen in man. 

The cochlea, so named from its resemblance to the shell of a 
snail, is a bony tube an inch and a half long, curled around a 
central axis so as to make nearly three spiral turns, each one ris- 



the ear: form and function 301 

ing above the former and the tube growing smaller in diameter to- 
ward the apex. This apex, or top, is called the cupola. A spiral 
lamina partly osseous and partly membranous winds around 
the axis of the cochlea, dividing the tube into two passageways 
which are separate from the base to the cupola where they 
unite by an orifice termed the helicotrema. One of these pas- 
sages terminates at the round window of the tympanum and is 
designated the scala tympanica, and the other passes into the 
vestibule and bears the name scala vestibuli. The interior of 
the membranous labyrinth is occupied by the endolymph, a 
serous liquid similar to the perilymph just described: it circulates 
through the scala vestibuli, the scala tympanica and the remain- 
ing intramembranous spaces. Although the amount of this fluid 
is very small, it serves to fill the delicate canals and to maintain 
the contour of their membranous walls, its pressure outward be- 
ing equalized by the inward pressure of the perilymph, which is 
interposed between the membranes and the exterior osseous wall 
of the labyrinth. 

The cochlear nerve, a branch of the auditory, has a great 
number of terminal filaments distributed over the internal sur- 
face of the cochlea and ending in the hair cells. This neural 
mechanism is termed the organ of Corti. 

The internal auditory meatus is an osseous canal less than an 
inch in length giving passage to the facial nerve and to the coch- 
lear and vestibular branches of the auditory with the trifur- 
cation of the vestibular, also to the auditory artery which 
divides upon the same plan as the nerve, the vascular and neural 
branches ramifying side by side. After leaving this meatus the 
trunk of the nerve proceeds to the hearing centers in the 
cerebrum. 

The physiology of the ear, like that of the eye and other 
organs of special senses, depends on the power possessed by cer- 
tain highly specialized nerves to interpret physical and chemical 
phenomena as sensations and perceptions of a particular and 
unique kind. The sensations and perceptions with which the 
ear is concerned are those of sound, and the phenomenon inter- 



302 NOSE, THROAT AND EAR 

pre ted is vibration or oscillation. Any elastic body, whether 
solid, liquid or gaseous, can be thrown into vibration and the 
organ of hearing can take cognizance of this occurrence. The 
ears of aquatic animals deal with vibrations of water and some 
such animals are nearly deaf when taken out of their natural 
element. As man normally lives in the terrestrial atmosphere, 
the great majority of vibrations which come to the human ear 
are transmitted through the air. When we speak of the external 
and middle ear having the function of "conducting," the word 
refers to the vibratory impulses which are conducted from the 
atmosphere to the receptive organism, the internal ear. The 
auricle is said to collect the wave-like oscillations taking place 
in the air and the ridges of the helix and antihelix, as also the 
depressions of the concha and triangular fossa, are supposed 
to render the process more complete. There is no doubt that 
undulations of the atmosphere transmitted through a tube are 
rendered stronger if the receiving end is expanded into a saucer- 
like concavity, with the orifice at the center, and the auricle, 
which has its orifice at the point of deepest concavity, exerts 
some such influence ; but observations upon varied formations of 
the cartilaginous plate and upon persons who through trauma- 
tism have lost a part of it, together with comparisons of the 
hearing of those with small and those with large auricles, lead 
to the conclusion that the rugosities and convolutions have only 
a slight effect either in rendering the oscillations stronger or in 
making them more distinct; an oval, concave plate of smooth 
surface appears to have equal, practical efficiency. 

The external auditory meatus continues the transmission of 
undulations and plays an important part by removing the tym- 
panum from the surface to the inside of the head where it is not 
only withdrawn by a full inch from an exterior position, in which 
it would be liable to many accidental injuries, but is inclosed in 
the petrous portion of the temporal bone, one of the hardest 
structures in the osseous system. In some of the lower animals 
the membrane is level with the skin and is easily destroyed. 
The head of the drum by its toughness gives much protection 



the ear: form and function 303 

to the delicate parts within and also supplies a vibrating tissue 
which changes the transmission through air to transmission 
through bone, represented by the ossicles, although some 
impulses likewise pass through the air incarcerated within the 
drum. After the membrana tympani, the chief road for the un- 
dulations is through the malleus, partly imbedded in that struc- 
ture, the incus, which articulates with the malleus, and the stapes, 
whose top is jointed with the incus and whose base fills the oval 
window. At this aperture there occurs another change in the 
medium of transmission for, as at the drum-head vibration in 
air gave place to vibration in a solid (bone), so here the medium 
is altered from a solid, the stapes, to a liquid, the endolymph, cir- 
culating through the scalae of the cochlea. As the drum is pro- 
tected by hard bony walls, so its included air is afforded an 
opportunity for safe condensation and rarification, under the in- 
fluence of changing temperature and other causes, by a canal, the 
Eustachian tube, a well-protected outlet and inlet for the air and 
for liquids as well. This tube performs the double function of 
ventilating and draining the middle ear and is also a collateral 
channel for the transmission of atmospheric undulations. 

In the cochlea there is another change in the medium through 
which the vibrations pass, this being from a liquid to a solid, 
from the endolymph to the terminals of the auditory nerve. 
At this stage in the process vibration, a physical phenomenon, 
becomes sound perception, a manifestation of vitality. This act 
of hearing, to which all the other processes lead up, is mainly 
performed in the cochlea, though some of the contiguous struc- 
tures supplied by branches of the auditory nerve probably 
take part in it. 

The statements already made rest upon a solid foundation. 
That vibrations proceeding from the middle ear produce effects 
upon the cochlea and that immediately afterward neural im- 
pulses pass from the terminal filaments of the auditory nerve 
to the auditory centers in the brain — these are facts universally 
accepted. The intermediate steps are not so sure. The 
process by which vibration transmitted to the cochlea becomes 



304 NOSE, THROAT AND EAR 

a neural impulse traversing the nerve is still a theme for theo- 
retical discussion. The anatomical structures are so minute 
and fragile that investigations are restricted to expert micro- 
scopists using high power lenses. Experience has shown in- 
dubitably that inquiries pursued under such conditions are 
subject to much difficulty and great liability to error. There- 
fore conclusions reached by these investigations must be re- 
ceived with caution and we must bear in mind the difference 
between fact and hypothesis. 

The theory of cochlear functions, which has won most favor 
among otologists, is advocated by Prof. Bezold of Munich and 
its main points are given in his lecture upon The Physiology 
of Hearing. 

"Von Helmholtz explained the power of the ear to distinguish 
tones of varied pitch and also to discriminate among sounds 
simultaneously heard by establishing the theory of the 
mechanical analysis of impressions of sound in the cochlea. 

"The rods of the zona pectinata in the basement membrane 
of the cochlea are stretched like the strings of a piano. Ac- 
cording to Henson's measurements they increase in length nearly 
twenty-fold from the shortest fibers in the base convolution to 
the longest in the cupola. Von Helmholtz recognized these 
rods as resonators for the whole scale, which are stretched by a 
complicated apparatus in Corti's organ and transmit their 
vibrations directly to the layers of hair cells of the auditory 
nerve. Any number of impulses, which reach these rods 
simultaneously will cause a corresponding number of them 
to vibrate simultaneously. The perception of those causing the 
highest pitch is accomplished in the basement coil and of those 
causing the lowest pitch in the cupola of the cochlea." 

Certain facts regarding the semicircular canals and also the 
elliptical sacculus and utriculus, with their contained otoliths, 
while not strictly a part of the physiology of hearing, have such 
diagnostic relations as will require their consideration further on, 
and the same is true of some details not necessary in the general 
outline given in this chapter. 



the ear: form and function 305 

In discussing the larynx attention was called to the fact that 
the gift of voice is restricted to a small part of the animal 
kingdom. A similar statement is true regarding the sense of 
hearing, though this is much more widely distributed than 
phonation. As we go from man downward through the various 
orders of animal life the auditory apparatus grows simpler and, 
on the lower levels, it appears adapted to three purposes only: 
to warn the animal of the approach of one of its natural foes, to 
aid it in its search for food and to recognize calls uttered by 
members of the opposite sex. Some of the mammalia, like the 
deer and the wolf, have very acute hearing for a narrow range of 
sounds, but the human ear alone is capable of great diversity in 
quality and a very extended register as to pitch. An ear which 
is free from disease and has been well trained is able to recog- 
nize notes originating in thirty-two double vibrations per second 
(the lower limit) and those due to 32,768 double vibrations (the 
upper limit). As the highest note in each octave signifies 
just twice as many vibrations as the lowest, the total range of 
appreciable tones is ten octaves. The lowest note of the fourth 
octave from the start is usually called the fundamental; it has 
the pitch given by the middle C of the piano keyboard and is 
produced by 256 double vibrations per second. 

It is a curious fact that the ear has a range of perception far 
greater than the eye. The different colors recognized by our 
vision depend on different rates of vibration in the luminiferous 
ether; the lowest number of oscillations producing the red ray, 
and progressively greater rapidity giving rise to orange, yellow, 
green, blue and violet, while beyond the violet there are atinic 
rays influencing chemical reactions, but giving no light because 
the eye is incapable of interpreting them. Now the rapidity of 
vibration increases from color to color, but before the rate for 
the red ray is doubled we have passed through the violet and into 
the darkness. So it appears that the eye can perceive only six 
color notes, less than one octave, while the ear recognizes in 
sound notes ten octaves, each containing seven, or a total of 
seventy notes. 
20 



CHAPTER XXVIII 
AURAL EXAMINATIONS 

An aural examination is concerned with three things: (i) 
The anamnesis, or history of the case; (2) the present condition 
of the organs as revealed by sight and touch (sometimes also by 
smell) both with and without instrumental assistance; and (3) 
the degree of sound perception indicated by acoustic tests. 
Every beginner should train himself to a systematic method of 
examination, the topics being taken up in logical order, so that 
each one suggests that which is to follow. A tyro may think 
such a plan slow and that he can go faster by picking out the 
important points in a haphazard fashion but those who have 
formed the systematic habit find it a great time saver. It also 
prevents their omitting details which otherwise are apt to be 
overlooked, necessitating subsequent inquiry. In addition, in- 
formation systematically acquired is far better retained by the 
memory. 

The anamnesis comes to us usually from the patient or some 
friend who accompanies him; their statements being occasion- 
ally supplemented by that of a physician previously in charge 
who has referred the patient for special treatment. A narrative 
of the case prepared by an observant and well-educated prac- 
titioner is likely to be of great value to the otologist. Unfortu- 
nately such a narrative is seldom furnished— most men are too 
much hurried to tell it or write it out — and the specialist must 
do the best he can with the halting story of the patient, who does 
not know many of the facts and has no nomenclature for those 
he does know. When it is possible to get an account from the 
former medical attendant, it is certainly wise to do so. 

306 



AURAL EXAMINATIONS 307 

The case history, useful in all diseases, has often a peculiar 
value in those of the ear, a value arising from the manner of 
telling it, aside from the facts communicated. When questions 
are asked during the physical and functional examination, the 
patient's replies are often rendered untrustworthy by an uncon- 
scious or subconscious bias, or by some neurotic hindrance. 
Statements regarding responses to the acoustic tests are often 
vitiated in these ways; but while telling the story of his past 
troubles, the patient acts naturally and frankly; his method of 
talking and his hearing, or failing to hear, question? put in dif- 
ferent tones of voice, will give to the experienced and tactful 
otologist a gieat deal of information on which he can rely be- 
cause it is elicited in a way that does not excite neurotic 
perversity. 

After learning the usual "identifying facts" — name, residence, 
age, marital relation, with number, sex and ages of children 
living or deceased, we should inquire as to the parents and grand- 
parents and also brothers and sisters, whether they have suf- 
fered from aural diseases and whether deaf-mutism has existed 
in any branch of the family. We must learn the occupation 
(which may be a causal factor) and the patient's habits and mode 
of life, also the state of his health from childhood, with any se- 
rious maladies or accidents. Coming now to the aural affection 
for which treatment is sought we inquire its supposed cause 
with the circumstances and date of its beginning; the progress 
it has made and whether there have been intermissions or periods 
of partial recovery. These facts have a bearing on the progno- 
sis which is more favorable if the disease is recent than of long 
standing; if due to nasal obstruction, than to some constitutional 
malady; also when partial deafness follows catarrhal attacks or 
the use of drugs, than when it is congenital or a sequel of trau- 
matism or some infection like that of scarlatina or tuberculosis. 
The above outline of interrogations is only suggestive of a proper 
wethod of verbal inquiry whose object is to bring out all facts 
mhich may throw light upon the present condition of the pa- 
tient. Any arbitrary plan would prove a hindrance rather than 



308 NOSE, THROAT AND EAR 

a help to a capable physician who must in this matter, as in all 
others, use his own judgment and common sense. 1 

The second stage in the examination ascertains the condition 
of the various parts of the auditory apparatus by sight and touch 
frequently assisted by diagnostic instruments. A number of 
these are described in Chapter III under the caption Armamenta, 
and, when they are mentioned in the following pages, that de- 
scription will be cited ; other instruments will be explained in con- 
nection with the use to which they are applied. 

For this physical examination the patient should occupy a 
strongly made revolving chair such as that described in Chapter 
III, which should have, in addition, a mechanism for raising or 
lowering the seat for a range of three or four inches, thus giving 
facilities for change of level as well as for bringing either the 
right or left ear under inspection, without removal from the 
seat or interference with the light. As sunlight is liable to in- 
terruption by weather changes and other causes, we must 
generally depend upon artificial illumination and this is satis- 
factorily supplied by the lamps, condensers and reflectors, de- 
scribed in Chapter III. 

It is best to begin the orderly examination by inspection with 
the unaided eye. This will collect more information than we 
would at first suppose; it tells whether the auricles and contigu- 
ous structures on both sides are symmetrical; whether an au- 
ricle is abnormally large or abnormally small; whether there is 
crop-ear, flap-ear, negroid ear (pouched lobule) or any other dis- 
figurement of the external cartilaginous part; also whether it is 
affected by furunculosis, herpes or eczema. It likewise notes 
the posture of the patient's head and the movements made 
when there is an effort to hear indistinct sounds. All these 
particulars and others should be the subject of observation. 

Palpation, i. e. touch, or pressure with the finger tips, will sup- 

1 The inquirer is not slavishly restricted to a mandatory list of questions nor 
to ask for some fact, which stands out before his eyes, like the doctor of whom 
it is told that a new patient, on entering the office, introduced her escort as her 
son; but a few minutes later the physician, following a list of questions, com- 
mitted the gross betise of asking her whether she had ever been married. 



AURAL EXAMINATIONS 309 

plement the knowledge gained by the eye. It detects the caloric 
change upon inflamed surfaces and the fluctuation in tumefac- 
tions when any motile liquid is present — serum, blood, or pus; 
it develops the peculiar pitting of saturated tissues in oedema; 
it detects crepitus and shows the presence or absence of tender- 
ness under pressure and of pain when traction is made upon 
the auricle. 

The curvature of the external auditory canal and the pres- 
ence of hairs at its entrance usually prevent visual inspection 
without instrumental aid very near the ostium, and the finger is 
arrested close to the same point by the narrowness of the meatus. 
In proceeding further, we require the assistance of a speculum or 
otoscope. While there are several varieties of aural specula in 
the market, I have found that the instrument devised by 
Gruber (Chapter III) answers all practical purposes. We select 
from a set of Gruber specula the one best fitted to the size of 
the meatus and sterilize it by boiling. If it has subsequently 
grown cold, it should be warmed before use to a temperature 
io° or 12 F. above that of the body. If the right ear is 
under examination, the surgeon, sitting on the patient's right 
side, seizes the auricle between the index and middle finger of his 
left hand and draws it upward and backward so as to lessen or 
wholly remove the curvature in the meatus; and holding the 
speculum between the thumb and forefinger of his right hand 
passes it into the canal, using very gentle pressure and stopping 
if there is pain. The position of the speculum must, of course, 
conform to the shape of the canal, whose perpendicular diame- 
ter is longer than the horizontal and the direction of the instru- 
ment is upward, forward and inward, or "it slants toward the 
nose." If the speculum is stopped and yet no obstacle is ap- 
parent it should be withdrawn and one of smaller size substi- 
tuted. Successful introduction is much promoted by the tact 
derived from practice. When the membrana tympani is 
brought into view its surface is well illuminated by rays re- 
flected from the head mirror and the triangle of greater bright- 
ness normally present should be clearly shown and also the 



}IO NOSE, THROAT AND EAR 

outline of a part of the malleus seen through the translucent 
tissues. The pearl-gray color, usually attributed to the drum- 
head is liable to some modification in health and may be greatly 
changed by disease. Siegle's otoscope and the Delstanche 
masseur (described in Chapter III) cause outward and inward 
movements of the membrane, which give a fair idea of its mo- 
tility and indicate whether any part of it is bound down by 
adhesions. 

The mastoid sinuses have important pathological relations 
not only to the tympanum but to intracranial structures and 
their condition may have much diagnostic significance. The 
passage by which they communicate with the tympanic cavity 
is a cell, the antrum, which opens upon the rear wall and, 
as this is behind the drum-head, it cannot be seen with 
the aural speculum; therefore, the information accessible is con- 
fined to that given by inspection outside that membrane and to 
touch. Swelling, redness, tenderness, or deep-seated pain in the 
mastoid region point to the existence of inflammation and its 
extent may, to some degree, be inferred by the severity of these 
symptoms. If, after the tympanic cavity has been emptied of 
pus it refills rapidly, there is a valid inference that the secretion 
conies from a large surface and hence that the mastoid sinuses 
as well as the tympanum are concerned in the process. Our 
diagnosis is necessarily more a matter of induction than of di- 
rect observation and the exact location of mastoid lesions is often 
revealed only during operation. Furthermore, in this region 
there is so much variation from the typical anatomy that the 
surgeon must be constantly on his guard. He may have made 
an incision through the soft parts over the site of the fossa sig- 
moidea and proceeds to cut through the periosteum, when sud- 
denly the blade penetrates deeply and a flow of dark blood shows 
that he has opened the lateral venus sinus. The accident oc- 
curs because in this particular skull the sinus, instead of being 
protected by a firm plate of bone, is covered by a mere scale 
hardly thicker than writing paper. The only way to avoid such 
mishaps is to proceed with continual caution, testing the nature 



AURAL EXAMINATIONS 311 

of each structure encountered, before taking the next operative 
step. 

The Eustachian tube drains and ventilates the tympanum, 
hence its permeability is a matter of much importance, and 
knowledge regarding this is the first object of the tube's exam- 
ination. There are several methods, all being alike in sending 
a current of air from the pharyngeal orifice and observing 
whether it reaches the tympanum, or is arrested on the way. The 
escape of the air at the upper end of the tube is recognized by 
the patient on account of the peculiar sensation produced. 
This is usually trustworthy but is liable to error and should 
be corroborated by use of the auscultation tube (see Chapter III). 
It is simply a yard of rubber tubing fitted with an ear piece for 
the patient and another for the physician, who judges whether 
the passage from the throat to the middle ear is open, partly 
by sound and partly by the impact of the air impelled into the 
tympanic cavity. He will learn by experience to recognize 
certain modifications of these sensations and to attribute them 
to altered conditions in the Eustachian tube or tympanum, 
or in both. 

Valsalva's method is the simplest plan and is adapted to 
cases where the tube is normal or but slightly obstructed. 
The inflation can be performed by the patient without assist- 
ance and is often entrusted to him. This is both an advantage 
and a disadvantage; on one hand it facilitates the daily dis- 
tention of the tympanum, in conditions where positive air pres- 
sure is beneficial; on the other, there is danger that the patient 
will make the distention too often and too forcibly, thus pro- 
ducing a relaxation of the drum-head. The procedure is very 
simple, the patient with his mouth shut takes a full inspiration 
and closes the nostrils by digital pressure; he then makes a 
forcible expiration. This forcible expiration causes a condensa- 
tion or positive pressure in the naso-pharynx and the air finds 
an outlet through the Eustachian tube toward the tympanum 
where, at the moment, there is less pressure and a condition of 
relative rarefaction. The expired breath will traverse the tube 



312 NOSE, THROAT AND EAR 

only when the lower orifices are patulous and, with the purpose 
of assuring this condition, many text books teach that at the 
moment of expiration the patient should swallow (Toynbee's 
experiment) . This is wrong and nullifies the Valsalva proce- 
dure; for in swallowing the velum palati rises and shuts off the 
naso-pharynx from the rest of the throat, so that the breath 
forcibly impelled upward by the lungs does not reach the 
Eustachian orifices. Around them in the naso-pharynx and in 
the nasal fossae there is a region of negative pressure continuing 
from the previous inspiration. While in the meso-pharynx 
and in the mouth there is positive pressure, no force is acting 
upon the air to impel it upward through the tubes. 

Politzer's method uses, instead of the expired breath, a 
column of air artificially impelled through the nasal passages 
against the orifice of the Eustachian tube. The intranasal 
blast is supplied by a Politzer air bag (Chapter III) which is 
held in the surgeon's right hand, while its nose-piece is in- 
serted into one of the nostrils and the alae nasi are com- 
pressed by the middle and ring fingers of the left hand. The 
pressure exerted is gentle, just sufficient to keep the nozzle 
steady and to close the nasal vestibule. It is never necessary 
or justifiable to press hard enough to cause pain or epistaxis. 
Dr. Strawbridge directed that when the bag and tube were in 
this position the patient should swallow some water, previously 
held in the mouth and, just as the larynx moved upward in the 
median line of the throat, the bag should be compressed impel- 
ling nearly half a pint of air into the naso-pharynx whence it 
would pass up through the Eustachian orifice made patulous by 
the act of swallowing. Dr. Gruber modified this technique by 
dispensing with the aid of deglutition and having the patient say 
the syllable " hick," in a forcible manner. This act causes a re- 
traction of the soft palate and a gaping of the Eustachian orifice, 
the effects following the act of swallowing, and the air bag is 
compressed at the rising of the larynx, as already described. 
The Politzer method is applicable to cases where there is more 
obstruction than would yield to the Valsalva plan. The pressure 



AURAL EXAMINATIONS 313 

upon the bag should at first be gentle and, if this fails to inflate 
the tympanum, the force should be cautiously increased, but 
never to any great extent if the obstruction is unilateral, be- 
cause the compressed air affects both sides and there should be 
little interference with the normal, unobstructed tube. As ob- 
struction requires more force in the air current, its effect when 
it overcomes the obstacle is proportionally greater and the blast 
entering the tympanum may distend the drum-head and impart 
to the patient a sensation which is very distinct though rarely 
painful. The sound perceived by the surgeon using the auscul- 
tation tube varies in accordance with the conditions present. 
A dull click or thud signifies the somewhat forcible entrance of 
the air into the tympanum; whistling or hissing indicates that 
there is a perforation of the drum-head, and bubbling or gurgling 
proves that there is a liquid of some kind in the cavity — a diag- 
nostic sign of decided importance. 

When efforts at inflation by the Politzer method prove 
fruitless, resort must be had to the Eustachian catheter. This 
is an instrument made of silver, or hard rubber, having a length 
of from four to six inches, one end being enlarged to a hollow 
cone to accommodate the nozzle of an atomizer or air bag and 
the other end having a very smooth bulbous terminal, to avoid 
wounding the mucous membrane. Back of this end the cath- 
eter has a curve, which is an arc of a circle, whose diameter is 
two inches, and near the conical end is a small ring fixed upon 
that side, which has the concavity of the curve, this ring indi- 
cating the position of the instrument when most of it is hidden 
in the nasal cavity. This description of the catheter conforms 
to the type usually sold in the shops and commonly found 
in use in the hospitals, but some high authorities teach that it 
should always be made of virgin silver and furnished as a 
straight tube leaving to the surgeon the opportunity to bend it 
to any shape he may desire and which the great flexibility of 
pure silver renders practicable. In their opinion a catheter 
whose curves are determined by the requirements of each case is 
a better instrument than one made upon the pattern of an un- 



314 NOSE, THROAT AND EAR 

changing model however good that model may be. Prior to 
the introduction of the catheter the nose should be thoroughly 
cleansed with a detergent spray and the instrument, sterilized 
by boiling, should be lubricated with sterile petrolatum. The 
use of cocaine is a mooted point. Some authorities advise 
applying a two per cent, solution to the walls of the lower meatus 
with a cotton carrier as a routine procedure; others claim that 
this is necessary only in hyperaesthetic persons. There is 
doubtless much difference among patients and a good deal 
among those examining them. A well-informed mind and a skil- 
ful hand may in many instances dispense with the anaesthetic. 
If it be found that the instrument is causing a great deal of dis- 
comfort it can be withdrawn and the membranes desensitized. 
With a different personelle, the use of cocaine may be necessary 
at the initial introduction of the catheter. 

To properly pass the instrument over the incisor ridge at the 
nasal vestibule the tip of the nose should be elevated, as far 
as it can be done painlessly. The pressure is exerted with the 
thumb of the left hand, while the catheter, warmed and oiled, 
is held by the right hand perpendicularly before the mouth, with 
the concavity of its curve toward the upper lip as illustrated in 
Fig. 107. 

The rounded nozzle of the beak is now introduced through 
the vestibule, the conical end raised until the catheter is nearly 
horizontal and, in this position, the instrument is moved very 
gently along the floor of the nose until its beak slides over the 
downward slope of the soft palate into the pharynx. The con- 
ical end is then rotated almost half a complete turn so that the 
guiding ring first points to the cheek upon the side under ex- 
amination and comes to rest pointing to the outer canthus of 
the corresponding eye. By this manceuver the beak which was 
directed downward takes a position with its point presenting 
upward and away from the median line. It is just in front of 
the cartilaginous lips of the Eustachian tube and slight pressure 
causes it to enter the aperture. As the curve of the catheter 
has now an upward inclination, its further movement along 



AURAL EXAMINATIONS 



315 



\S ^ 



tv 



K 



4> 



ST-^n 



FlG- Ioy .__ Passage of Eustachian catheter. The tip of the nose is elevated 
and the point of the catheter enters the vestibule. 



316 NOSE, THROAT AND EAR 

the nasal floor will increase the distance it penetrates the tube. 
The patient aids the entrance of the beak by swallowing at the 
moment it reaches the orifice and its enclosure by the Eustach- 
ian labia transmits through the catheter to the directing hand 
a peculiar sensation, easily recognized by those who have had 
experience. One new to the work may fail to interpret this 
sensation and not feel sure that the procedure has succeeded 
until he has the proof furnished by inflation which is accom- 
plished as follows : The left hand releases the nasal tip and keeps 
the catheter steady, holding it between the thumb and fore- 
finger, while resting the other fingers upon the bridge of the nose; 
the right hand grasps the Politzer bag, fits its nozzle into the 
hollow cone of the catheter and then by compressing the bulb 
sends a blast of air through catheter and tube into the tympanic 
cavity, its arrival there being indicated by the sounds heard 
with the aid of the auscultation tube, just as in the Politzer 
method. 

It is proper to begin invariably by gentle compression of the 
air bag and to use more force only as required by resistance en- 
countered. Such resistance can be estimated with the cath- 
eter better than by the air-bag inflation alone, because the draft 
impelled to the tympanum reaches only one ear and has less 
opportunity to escape in lateral directions. In fact, it has con- 
siderable impulsive and divulsive power and if, after repeated 
attempts, no air reaches the tympanum, the conclusion is ob- 
vious that there is stenosis of the Eustachian tube, a morbid 
condition in which the catheter plays a part in treatment as well 
as in diagnosis. To make the examination of the middle ear 
complete, it is necessary to take into account abnormalities of 
the nose and pharynx, both structural and functional. They 
are important causal factors in aural disease and are necessarily 
included in a thorough diagnostic study. 

The next stage in aural examination is the measurement of 
hearing or the estimation of the perception of sound. This is 
also called functional examination, because it is concerned with 
physiologic acts, either normal or impaired. The internal ear, 



AURAL EXAMINATIONS 317 

the perceptive mechanism, is hidden from view; morbid changes 
in its anatomy are (while the organ is unmutilated) known to us 
by inference only, and we are deprived of the aid given by the 
direct physical examination of the structures. This is a great 
drawback in both diagnosis and therapeutics and puts otology 
to a disadvantage suffered by few of the other specialties. 
Acoustic tests are used to determine the quantity, or loudness, of 
sound and also its quality. By the former we learn whether 
the hearing falls below the normal standard and the extent of 
that deterioration ; from the latter we draw inferences as to the 
part of the ear whose function is impaired. Quantity, which 
depends not upon the number of vibrations but upon their 
intensity, is the measure of the audition or hearing power. 
This power may be ascertained by using a resonator, which 
accurately produces and records quantities, beginning with a 
slight resonance and successively magnifying it through a 
sufficient scale of augmented intensities. When the audition 
of a defective ear is to be measured, the resonator adjusted for 
the smallest quantity is placed at the normal distance; that is 
the distance at which it is just audible to the normal ear. Of 
course it is inaudible to the defective ear being tested. In- 
creasing power is then applied and the resonance continuously 
magnified until it becomes audible to the defective ear. This 
resonance recorded upon the scale expresses the amount of de- 
fect or impairment of the ear under examination and inversely 
the amount of hearing which remains. This balance of func- 
tional power is expressed by a number and as it is always less 
than normal, the number is always a fraction. The numerator 
is one and the denominator is the number shown on the scale 
when the magnified resonance became audible to the defective 
ear, e.g., if it was necessary to magnify the resonance sixteen 
times before it could be heard, the fraction would be one- 
sixteenth and would signify that the tested ear retained one- 
sixteenth of its normal hearing power. 

In some respects this method of measuring the functional 
power of the ear is the best possible; it is easily understood, 



315 XOSE, THROAT AND EAR 

requires hardly any mathematical calculation and yields results 
which are accurate and trustworthy. Nevertheless its use is re- 
stricted to the laboratories of physicists and physiologists. In 
otologic practice its advantages are counterbalanced by a prac- 
tical objection, the difficulty of securing a mechanism which will 
produce and record the various- quantities in a satisfactory 
manner. Instruments, or rather machines, for this purpose 
have been invented and some of them display remarkable in- 
genuity in construction and attain great accuracy in producing 
and recording the vibrations, which serve as a means of measur- 
ing auditory power; but these machines, like many other con- 
trivances employed in acoustics, are difficult to make and are 
quite expensive. Because of their elaborate construction and 
delicacy of adjustment they are easily put out of order and are 
not well suited to the usual conditions of medical practice. 

For these reasons quantitative tests in otologic work are 
very rarely made by the direct method of magnifying the 
resonance; instead of this, the usual method employs a reso- 
nance of unchanging intensity which can be obtained from sev- 
eral kinds of resonators which are simple and inexpensive. 
This plan is based upon the acoustic principle that quantity 
varies inversely as the square of the distance between the reso- 
nator and the ear, and as quantity is the measure of audition 
or hearing power, this also is computed upon the squares of the 
distances from the resonator to the ear. A resonator of unchang- 
ing power is tried with a number of normal ears to determine 
the greatest distance at which they can hear it. The average 
of these distances is called the normal distance and is expressed 
in units of length, such as feet or inches. The distance at 
which the same resonator becomes audible to the defective ear 
is measured and expressed in the same units. Remembering 
that the greater the defect in hearing, the greater must be the 
quantity to offset that defect, we can calculate the proportion 
of hearing power which still remains. If, for example, we take 
the same case as that used in the direct quantitative test al- 
ready given, we have the following figures: normal distance, 



AURAL EXAMINATIONS 319 

twenty inches; distance for defective ear, five inches; square of 
normal distance, 400 inches; square of distance for defective 
ear twenty-five inches; therefore, the hearing power will be 2 ^oo> 
or, by reduction, one-sixteenth. This power may always be 
expressed in a fraction whose numerator is the square of the dis- 
tance between the resonator and the defective ear and whose 
denominator is the square of the normal distance. 

This method is in nearly universal use, for it is easy to alter 
the distances between the ear and a resonator of unchanging 
power, which can be readily procured; while, as has been re- 
marked, the other method in which the distance remains con- 
stant and the resonator has varied intensities, requires elabor- 
ate and expensive apparatus ; but the plan so commonly followed 
is not free from objection. The calculation introducing the 
squares of numbers expressing distances has confused the minds 
of some authors, as is proved by the mistaken statements found 
in several well-known text books. The authors of these works 
direct us to express the hearing power by a fraction, using the 
measured distances, not the squares of those distances. In the 
illustration already used, the erroneous method of these authors 
gives the audition as five-twentieths or one-fourth, when in 
reality it is only one-sixteenth, quite a serious error; for one- 
fourth audition expresses marked hardness of hearing, which 
is still compatible with work in many occupations, while 
one-sixteenth is only a small remnant of the function near the 
boundary line of entire deafness. The errors arising from this 
fallacious calculation are so great that it is hard to see how an 
otologist can go on treating a patient for many days or weeks, 
without discovering that his diagnostic determination of the 
hearing power was very far wrong. 1 Such a discovery should 

1 One unfortunate result of such mistakes is their effect upon suits for damages, 
in which it has been proved that the plaintiff's hearing was injured through the 
fault of the defendant. In fixing compensatory damages the jury accepts the 
expert's testimony as to the degree of disability. If one of these authors is the 
expert, or if his book is accepted as authority, the plaintiff will be adjudged to 
have far less disability than he actually suffers and a gross injustice will be done 
to him, because the "expert" professor went astray regarding a familiar law of 
acoustics. 



320 NOSE, THROAT AND EAR 

bring to light the fault in the calculation and result in the 
author's correcting the misleading instructions given in his book; 
but years go by, edition follows edition, and yet the glaring mis- 
take remains to misinstruct students and to confuse physicians. 
We can hardly escape the unpleasant conclusion that these emi- 
nent authors have not compared their published statements 
with the facts of their own actual experience, though this is the 
confident claim made for the value of their books. They are 
professors and one cannot help wondering whether their college 
lectures also are divorced from the realities of otologic practice. 
In the routine of daily work most quantitative tests are made 
with a tuning fork, a watch, or the voice, of which only the tun- 
ing fork has a standardized resonance and even with it allow- 
ance must be made for certain discrepancies. If absolute 
accuracy were to be attained, the apartment used for aural tests 
would require entire silence, just as that employed for scientific 
experiments in photometry requires facilities for producing total 
darkness. Our actual environment is very far from such a con- 
dition. In selecting an office, it is seldom that any attention is 
given to the acoustic properties of the room, its production of 
echoes and nonvibratory centers due to the counteraction of 
acoustic waves; yet these properties have an influence upon 
the tests, in some rooms a decided influence. There are also 
the noises produced by movements outside of the room and 
even of the building; "the city's ceaseless, complex hum;" 
and these too are factors in the composite oscillation envelop- 
ing both patient and physician and modifying the results 
reached in the examination. In consequence of these con- 
ditions, each otologist must work out for himself a method 
whose chief factors are the power of the resonator and the 
square of its distance from the normal and from the defective 
ear, while its minor factors are peculiarities of room, house and 
street. If he keep steadily in view the acoustic laws bearing 
on the subject and observe and appreciate all the peculiar 
features of his environment, he will develop a technique which 
will yield satisfactory results. They will not reach mathe- 



AURAL EXAMINATIONS 321 

matical accuracy, but will furnish all that is necessary to deter- 
mine the approximate degree of disability and — what is more 
frequently needed — a correct guide for treatment. The 
variation from perfect accuracy is, in good practice, rarely more 
than five per cent. 

The tuning fork best adapted to quantitative examination 
is one of low pitch, about 200 V.D. Overtones which are 
numerous in forks for this part of the register should be 
eliminated, either by clamps or by the way in which vibration 
is excited. The normal distance of the fork having been ascer- 
tained by averaging a number of observations made in the special 
environment of the otologist, this distance and its square should 
be recorded either on the fork itself, or on the shelf where it 
lies. The distance for the ear under examination is ascertained 
by causing the fork to vibrate, when held horizontally with 
the tines pointing to the ear, and then advancing it from 
the normal distance (where it is inaudible) to a station where 
it is heard. The distance separating this station from the 
ear and the square of this distance are entered in the record 
of the examination. It is very desirable to compare the results 
of the fork test with those given when other resonators are 
employed. 

The tick of a watch produces two sounds, both of which 
are impure tones occasioned incidentally by the time-recording 
movement, without any design that they should serve any 
otologic purpose. Nevertheless, the watch, which was the 
first mechanical resonator used to measure the audition, 
holds its place on account of its convenience. The normal 
distance for the watch devoted to this use should be ascer- 
tained, as was done for that of the tuning fork, and this with 
its square should be recorded inside the case, so as to be al- 
ways available. In testing impaired hearing, the watch should 
be advanced from the normal distance to a station where the 
tick becomes audible to the defective ear. As with the tuning 
fork, it is better that the resonator should find its station by 
approaching the ear than by receding from it. 



32 2 NOSE, THROAT AND EAR 

Testing with the human voice, while liable to many fallacies, 
has a feature of great value in the fact that the ability to hear 
speech is beyond all comparison the most important phase of 
the auditory function, and the ratio in which this ability 
is retained is often somewhat different from the ratio ap- 
plying to other sounds. The voice can be standardized by 
the phonograph which gives reproductions of unvarying 
character as to both quantity and pitch. Most examinations 
are made by direct use of the physician's own voice, employ- 
ing in vocalization only the reserve air which remains in 
the lungs and bronchi after an expiration. The vocal vibra- 
tions caused by this remainder are much less variable than 
those excited by the stronger current passing through the 
larynx in the usual expiratory act. 

In using words as a test, it must be remembered that certain 
letters of the alphabet represent more quantity than others, 
irrespective of phonatory force applied by the speaker. Ac- 
cording to Blake's table, T has the greatest intensity and M 
the least. Furthermore, familiar words and sentences must 
be avoided to eliminate the influence of mental suggestion 
which, when a few sounds are actually heard, supplies what 
are lacking by the laws of association. A quick-witted patient 
often makes correct guesses regarding what is uttered by 
watching movements of the oral muscles, even without any 
special training in lip reading, hence the speaker's face should 
be averted. The relations of distances to quantities are just 
the same in tests with the voice, as when use is made of me- 
chanical resonators. 

While the ordinary clinical requirements of quantitative ex- 
amination can be met in the ways just described, it is proper 
to mention a set of resonators which has attracted atten- 
tion in all countries and has excited much interest in the 
United States, as is shown by a large importation, in spite 
of a high price (about $200). These instruments are capable 
of producing all the rates of vibrations audible to the human 
ear and most of them have a constant, invariable intensity. 



AURAL EXAMINATIONS 323 

They are designed for both quantitative and qualitative tests 
and, being strong and durable, are free from the objection to 
the machine resonators that are hard to keep in order. The 
set comprises seventeen pieces : fourteen forks, two closed organ 
pipes and one whistle, and is the joint production of Bezold 
and Edelmann, the former a professor in the University of 
Munich and the latter an instrument maker of the same city. 
In determining the existence of the so-called islands of hearing 
remaining in the cochlea, when much of its function has been 
lost, this complete set of resonators is invaluable and each 
separate instrument appears to have great excellence both as 
to mathematical accuracy and mechanical workmanship. 

Qualitative tests, conducted with graded tuning forks and 
the Galton whistle (Chapter III), determine the perception of 
pitch and their main value arises from the fact that diseases 
of the external and middle ear interfere more with the low 
tones, produced by the slower vibration than with the high 
tones caused by more rapid vibration, while diseases of the 
internal ear have a precisely contrary effect, damaging the 
high tones more than the lower ones. Therefore when by 
quantitative tests we have determined the defect existing in 
the function, qualitative examination will guide us in search- 
ing for the lesion responsible for impairment; if hearing in 
the lower register has suffered most, we conclude that the 
conducting apparatus is at fault; if the main failure is shown 
in the upper tones, there are morbid changes in the labyrinth. 

Rinne's tests are positive and negative. In the first, a 
vibrating tuning fork is set upon some spot in the median 
line of the skull and kept there until it becomes inaudible. 
Without being again struck, it is held close to the meatus of 
the ear under examination. If in this position there is re- 
surgence of the sound, it is concluded that the acoustic in- 
tegrity of the conducting apparatus is maintained, though 
various morbid processes may affect some parts of the external 
or middle ear. In the second or negative test the vibrating 
fork is first held close to the external meatus and, when it 



324 NOSE, THROAT AXD EAR 

becomes inaudible, is transferred to the median line of the 
skull. If in this position the fork is heard, the result proves 
that the conducting apparatus is in a morbid condition. The 
conclusions reached by Rinne's tests are vitiated if there is 
disease in the middle ear and also in the labyrinth. 

The Weber test for bone conduction is made by placing a 
vibrating fork (about 256 V.D.) at different points upon 
the cranial median line and observing whether it is heard better 
in the normal or the defective ear. In the former case the 
lesion is in the labyrinth because the internal ear on both 
sides is generally accessible to bone conduction and therefore the 
better organ yields the better perception, but in the latter 
case, where audition is better in the impaired ear, the lesion is 
in the external meatus or in the middle ear, because air vibra- 
tions are partly cut off on that side and do not interfere with 
the labyrinth which is exclusively affected by the osseous 
vibrations and hence perceives them more acutely than the 
labyrinth on the other side, although both are normal. 

In the Gardiner-Brown test, a lightly vibrating fork is 
placed upon the bridge of the nose and the surgeon notes how 
long the tactile sense in his fingers can recognize the vibra- 
tions and if they cease at the same moment that the fork 
becomes inaudible to the patient. Normally the cessation 
of the two sensations is simultaneous and if the hearing stops 
first, there is a diminution in the bone conduction or a lesion 
in the internal ear. This test is made in another way by 
placing the fork upon the patient's mastoid process and at 
the moment it becomes inaudible transferring it to the mastoid 
of the surgeon. If he hears nothing, he judges the patient's 
bone conduction and labyrinth to be normal, but if the fork 
is audible to him either the osseous transmission or the per- 
ception is impaired. It is obvious that this form of the Gard- 
iner-Brown test presupposes that the surgeon's ear is in a 
perfectly normal state. There is also a chance for error in both 
forms of this test because the bone conduction notably de- 
creases after the forty-fifth year and, if the ages of patient 



AURAL EXAMINATIONS 325 

and surgeon are upon different sides of that line with a con- 
siderable interval between them, the conclusions as to disease 
are likely to be vitiated. 

Comparative observations of bone and air conduction have 
recently so largely engrossed attention that a test of the middle 
ear devised by Politzer, years ago, has fallen into partial dis- 
use, but it is still much esteemed by several high authorities. 
The procedure is simple: a fork of low pitch (about 256 V.D.) 
is thrown into strong vibration and held close to the nostrils; 
the intensity is observed and then the patient swallows, by 
that means opening the Eustachian tubes. If the tubes and 
tympana are free from obstruction and suppurative or hy- 
perplastic changes, the sound is notably louder during the 
moment of deglutition, when the intratubal column of air 
vibrates, but if the obstacles mentioned are present, then the 
sound is fainter because deglutition vibrations interfere with 
those taking the circuitous route over the cheeks to the ex- 
ternal meatus. By repetitions this test gives quite accurate 
information regarding the comparative condition of the middle 
ear upon the right and left side, both as to the patulency of 
the tubes and the normality of the tympanic cavity. 



CHAPTER XXIX 
THE EXTERNAL EAR : DEFORMITIES AND DISEASES 

Anatomically described (Chapter XXVII), the external ear 
includes the auditory structures outside of the membrani 
tympani, or drum-head. These structures are not infrequently 
the site of deformities, either congenital, developmental, or 
traumatic. Many of these are merely disfigurements which 
do not impair the auditory function or injure the general health. 
They cannot for these reasons be ignored as trivial, for some- 
times they are very unsightly and inflict mental distress greater 
than would be caused by even marked dulness of hearing 
which is unilateral. Caleidic operations ingeniously adapted 
to individual conditions have done much to ameliorate these 
disfigurements; they are within the legitimate province of 
caleidic surgery and should not be turned over to tradesmen 
outside of the medical profession. There are other deformities 
which are not only unsesthetic, but injurious to the hearing 
and to the constitutional health, directly or indirectly. Such 
obviously require our attention. 

Atresia of the meatus, when congenital, is apt to be asso- 
ciated with a rudimentary condition of the ossicles and with 
absence of the membrana tympani. In such cases the closure 
of the canal serves to protect the tympanic structures which 
would otherwise be exposed, and it is best not to interfere 
with the abnormality unless the occurrence of suppuration 
in the middle ear makes such action imperative. This con- 
genita] atresia impairs hearing less than would be expected. 
Children with such deformity learn to speak and subsequently 
functionate reasonably well. 

Acquired atresia may result from traumatism, but is com- 
monly a sequel of long-continued inflammation causing thick- 

326 



THE EXTERNAL EAR 327 

ening of the cartilage and the fibrous tissue. As otitis media 
is very often coincident with the occlusion of the canal, it be- 
comes necessary to restore the lumen of the meatus for the 
sake of drainage and to secure access to the middle ear. The 
hyperplastic tissue may be softened and absorbed under 
several weeks' treatment by electrolysis, the negative electrode 
being used with a partly insulated needle at various points 
along the interior of the canal, while the positive, inclosed in 
a large sponge, is applied over the thick muscles of the back or 
shoulder. A galvanic current is employed upon alternate 
days for ten or fifteen minutes at a time. When the con- 
striction is caused by annular bands, these may be divided 
at two or three points in their circumference and dilators used 
to keep the canal fully open until granulations fill the spaces 
left by the incisions and the normal lumen is restored. The 
meatus is sometimes obstructed by bony growths whose cause 
is obscure, and they may obtrude somewhat without causing 
any symptoms. The term exostoses is applied to those ap- 
pearing as white nodules of spheroid shape, sometimes pedun- 
culated, while hyperostoses are diffuse, sessile growths upon 
the lower wall of the canal. When inactive and innoxious 
these enlargements should not be disturbed, but when they 
are extending so as to interfere with drainage or to impair the 
hearing, they should be extirpated by incising and retracting 
the integument and then removing the superfluous bone with 
chisel, gouge, or forceps, care being taken not to injure the 
walls of the canal. 

Appendices are abnormal extensions of the cartilage of 
the auricle. They nearly always appear in front of the tragus 
which is smaller than natural and sometimes rudimentary 
as though the cartilage had grown in the wrong direction. 
Such an anomaly is properly removed by dissecting back 
the overlying skin, excising the cartilage and bringing the 
edges of the wound into neat coaptation. 

Fistula auris is a congenital deformity consisting of a pouch, 
located in front of the tragus, and having an interior lining 



328 NOSE, THROAT AND EAR 

formed of invaginated skin. At the point where this reflected 
integument joins that outside there is an orifice leading to 
a short canal that when inflamed becomes the fistula from 
which the condition takes its name. The irritation of this 
tract and consequent suppuration is due to desquamation of 
the epithelium of the invaginated skin. This process seems 
to remain in abeyance for long periods during which the ab- 
normal pouch gives rise to no symptoms. Then desquamation 
occurs, the cast-off epithelium cannot escape, it undergoes 
decomposition, produces capillary congestion by pressure 
and pus is formed. When this takes place, the only satis- 
factory treatment is extirpation. The fistula is explored with 
a large probe and then slit throughout its length with a straight 
bistoury; all the contents are turned out and the dermal lining 
removed with a curette. The denuded surfaces are then ren- 
dered aseptic, brought together and retained in apposition by 
adhesive strips or sutures, so that the healing process shall 
obliterate the cavity. 

The auricle, from its exposed position, is liable to traumatism 
of many kinds. In general the treatment required is that 
applicable to wounds in other parts of the body, with modi- 
fications due to peculiar anatomical features. As the carti- 
laginous framework is covered by the skin with very little 
interposed muscular tissue, contusions are especially liable to 
give rise to haematomata, the extravasated blood lacking the 
normal pressure exerted by the muscles. So, too, lacerated 
wounds of the thin plate of cartilage and skin require special 
care to secure and maintain proper coaptation of the edges, 
because the structure has little inherent tonicity. 1 The ex- 

1 Traumatism, as seen in our day, is nearly always the result of accident. 
The intentional cutting or tearing of the auricle is now rare, but was common 
in times not very remote, when physical mutilations were punishments inflicted 
by the courts of law. As late as the colonial period of our own country, the 
penalty for certain crimes was the amputation of one or both ears. That 
barbarism is nearly obsolete, but a vestige remains in the mutilation of the 
auricular lobe to suspend a ring or "ear-drop." In the last generation this was 
a common practice, not by the behest of law, but by the mandate_of fashion. 



THE EXTERNAL EAR 3 20. 

ternal ear is liable to two injuries which frequently occur in 
disasters, such as the fall of buildings, railroad wrecks and 
serious accidents caused by machinery. The first .is fracture 
of the meatus. The canal may suffer rupture in either its 
cartilaginous or bony section and the injury may be caused 
by either direct violence or by indirect force (counter-stroke) 
transmitted through the contiguous tissues. The symptoms 
are variable. The pain felt at the moment of injury is often 
confused with other suffering due to the accident. Bleeding 
sometimes occurs. Subsequently there is apt to be tenderness, 
giving rise to pain due to strong vibrations when loud sounds 
are heard but the diagnosis can be established only by careful 
inspection with the speculum and exploration with a blunt 
probe. The chief factor in treatment is physiological rest. 
Syringing may do harm and should be avoided but dis- 
charges, if they occur, can be carefully wiped away and the 
cleansed surface treated with a saturated solution of boric acid, 
employing for both objects a small cotton-tipped applicator. 
Between treatments a sterile dressing should be kept over the 
entrance to the injured meatus and, as far as possible, the 
patient should be protected from loud noises. 

The other traumatism is most frequently caused by rapidly 
moving machinery and especially by driving belts transmitting 
motion between swiftly rotating wheels. If the hair becomes 
entangled in such a belt the soft parts from the vertex to the 
angle of the lower jaw may be torn loose and either wholly 
severed or left hanging as a great, ragged flap bearing the 

It is still prevalent among the peasants of some countries, as anyone may see 
who looks at a throng of recently arrived immigrants. Another relic of the old 
brutality is the cuffing and jerking of the auricle to punish children. Pain can 
be inflicted in a score of ways which do no permanent physical harm to the cul- 
prit, and yet many parents with amazing stupidity twist the auricle or subject 
it to sharp blows. Since it is their own offspring with whom they deal, they 
can use methods which the law forbids to the schoolmaster. This cruel and 
senseless practice has done untold injury to the delicate aural mechanism of 
children and is responsible for partial deafness in thousands of adults who were 
subjected to it in their early years. 



330 NOSE, THROAT AND EAR 

entire auricle and with it part of the meatus. To replace 
this flap and secure proper coaptation is difficult; even when 
union is secured the auricle is apt to be out of place. The 
resulting atresia of the meatus is often unimportant for 
usually the injury wholly destroys hearing on that side. If 
an effort is made to restore the canal a cruciform incision 
must be made through the flap and an opening maintained by 
cotton or other plugs till its margin heals. 

The auricle is not likely to shelter foreign bodies but they 
find their way into the meatus in great variety, both as to 
shape and substance. The seeds, pebbles, buttons and other 
inanimate extranea owe their introduction to the fondness for 
experimenting on their own bodies, which is very strong in 
many children. Once in the meatus, the article may remain 
because the child cannot get it out, or because it is forgotten. 
The ears of the insane and the feeble-minded become receptacles 
of odds and ends for similar reasons. Curiously enough, 
the ultimate damage consequent upon this misuse of the meatus 
is due less to the immature and defective than to the adult 
and rational people; for these extranea seldom do much harm 
to the walls of the canal or to the aural function, but very 
serious injury often follows harsh and unskilled attempts 
to remove them, and these attempts are made by those who 
are mature and presumably rational. There is so much danger 
in rough-and-ready methods of extraction that it is not super- 
fluous to caution even the physician. The safe course is to 
depend upon the syringe and water at the temperature of 
ioo° F. to loosen the foreign body, when patient and care- 
ful manipulation will alter its position sufficiently to afford a 
crevice for introduction of the blunt hook, with which it can 
be dislodged. 

Animated intruders are sometimes found in the meatus; much 
more frequently in tropical countries than here. The ova of 
insects are deposited in the canal, either beneath the skin or 
under a layer of the cerumen and the insects themselves are 
sometimes held fast by this tenacious substance. They are 



THE EXTERNAL EAR 33 1 

usually dead when found, but sometimes remain alive for 
many hours causing much alarm by the noise they made, a 
noise which sounds loud in the confined space of the meatus. 
These intruders should be killed by instilling a little chloro- 
form, or kerosene, and then dislodged by a jet of water. If 
after thorough use of the syringe the patient still thinks 
something is moving in the canal the meatus should be loosely 
packed with absorbent cotton saturated with mucilage of 
acacia and the plug retained for several hours. Any insect 
living or dead will be entangled in this adhesive mass and 
come with it when it is taken out, as will also any eggs 
deposited upon the dermal lining of the canal. The muci- 
lage is quite harmless and any of it which remains is easily 
washed away. A meatus which has harbored any living thing 
should be kept under observation for a short time to make 
sure that any larvae produced from ova deposited under the 
epidermis are found and destroyed. A repulsive form of 
insect intrusion is seen in neglected children, suffering from 
chronic, purulent otitis media ("mutton ears")- P us accu- 
mulates in the concha and drips from the lobe, attracting large 
numbers of insects, which deposit their eggs in all parts of 
the external ear. Thus the meatus becomes infested with 
maggots which emerge from it and crawl over contiguous 
surfaces — a disgusting sight! The entire locality should be 
thoroughly sprayed with nebulized chloroform. This kills 
the larvae: their reproduction must be prevented by keeping 
the auricle clean and removing pus from the meatus as rapidly 
as it collects. 

Ceruminous accumulations are intermediate between ex- 
traneous obstructions and disordered secretions, showing 
features of both. The cerumen, or ear-wax, is a physiological 
exudate of sub-dermal glands but it often becomes thick and 
inspissated, forming a firm plug which fills the lumen of the 
meatus for variable distances. If the accumulation reaches to 
the tragus it is observed and the dangerous ear spoon em- 
ployed to remove it, but when the impaction is limited to 



332 NOSE, THROAT AND EAR 

the deeper parts of the meatus it often escapes notice until some 
impairment of hearing leads to a medical examination. Aural 
examinations (for insurance, for occupations and other purposes) 
often bring to light plugs of inspissated cerumen, which nearly 
fill the deeper section of the canal and which have existed 
for a long time but have not affected the hearing. These 
facts and others lead to the conclusion that, as a rule, such 
accumulations have little effect upon the function of the ear; 
but there are many exceptions. 1 

In some cases impacted ear-wax may be removed by direct- 
ing against it jets of hot water, 115 F., impelled by a syringe. 
If, however, the plug is much hardened, this is a tedious pro- 
cedure and it is better as a preliminary to soften the mass 
in which there are often beside the cerumen, epithelial scales, 
dust and detritus of various sorts. This softening may be 
effected by a solvent liquid like the following: 

1$. Sodii bicarbonatis gr. xx 

Glycerini fl. 5j 

Aquae q.s. ad. fl. 5j- M. 

This should be instilled with a dropper to thoroughly moisten 
the impacted mass and, when the fluid has been absorbed 
more should be added at intervals, until the plug becomes 
pultaceous. The mass is then washed away with the water 
jet and the interior of the meatus thoroughly dried with a 
cotton-tipped applicator. Ear spoons and similar imple- 
ments often do much harm; they certainly should not be 
used in any case by unskilled hands. After the removal of 

1 A man of twenty-five, a clerk in a railroad office, suffered rapid deterioration 
of hearing; six weeks after he first noticed the defect he had become unable to 
understand general conversation. On account of some prejudice he was averse 
to seeking medical aid but at last, in fear of losing his employment, he consulted 
a specialist. Each meatus was clogged by a sort of compost — dead epithelial 
cells, dust and inspissated cerumen — the whole being impacted into a firm mass 
which proved hard to soften. When the entire accumulation had been removed 
the man's hearing was found to be normal in both ears. Such a case is excep- 
ceptional but may occur any day. The cure however easy is very impressive 
to the patient and to overlook this condition and follow a wrong course of treat- 
ment is very unfortunate. 



THE EXTERNAL EAR 333 

aTlarge ceruminous plug, the meatus may be sensitive and 
irritable until it becomes accustomed to contact with the 
air long shut out. This condition is relieved in a few days by 
liquid petrolatum applied upon a pledget of cotton. 

The other morbid states of the external ear are classed as 
diseases, nearly all of an inflammatory type. Of these eczema 
is the most important, on account of its prevalence and the 
intractable character it shows in this locality . Two-thirds of 
all cases of disease of the external ear are referable to eczema, 
in one or another of its protean forms, nearly all of which may 
be either acute or chronic in their course. Eczema erythem- 
atosum is characterized by redness, swelling, and slight scaling, 
with itching and burning; eczema papulosum by great numbers 
of minute, acuminate papules and severe pruritus; eczema 
vesiculosum by numerous small vesicles upon a patch of con- 
gested skin, very itchy and tending to rupture, leaving a raw, 
weeping surface, soon more or less covered with desiccating 
crusts; eczema pustulosum by aggregations of pustules, break- 
ing down and discharging their contents which form thick yellow 
scabs. These four kinds of eczema may be regarded as pro- 
gressive manifestations of a diseased process which shows 
successively, congestion, papules, vesicles and pustules, but 
in any particular case some part of the process may be slight 
and hardly noticed. Eczema squamosa is a variety dis- 
tinguished from the erythematous form by the rapid separa- 
tion of large scales. Eczema rubrum is secondary to pustula- 
tion and is characterized by large circumscribed areas, whose 
surface is raw, moist and of a dark red color, these patches being 
ultimately covered by thick crusts. 

Pathologically, eczema begins with general vascular con- 
gestion of the cutis and sub-cuticular tissues which is followed 
by serous infiltration of the dermic layers and in chronic 
cases of the connective tissue. The serum exuded upon the 
surface has undergone changes, which make it an irritant, and 
it^excoriates sound skin over which it flows and excites the 
formation of pus. What alteration occurs in the plasma of 



334 NOSE, THROAT AND EAR 

the blood is not determined; many believe it to be the same 
which takes place in persons of the rheumatic diathesis, but 
the primary conditions are obscure. Poor hygienic surround- 
ings and uncleanly personal habits have a place among pre- 
disposing causes as also has suppuration near-by, as in otitis 
media. Auricular eczema is at times an extension of the 
disease from the face or scalp. Exciting causes include in- 
judicious scraping with the finger nails or instruments, macera- 
tion from the prolonged use of warm, damp dressings, and 
the pernicious mutilation of the lobe for the suspension of 
jewelry. Although eczema of the external ear is usually 
more obstinate than the affection in other regions and proves 
particularly intractable when located upon the folded skin 
between the auricle and mastoid process, yet the prognosis is 
favorable if the patient will, for a sufficient period, follow 
faithfully a judicious plan of treatment which is adapted to 
peculiarities both of the individual and of the locality affected. 
The first step in treatment is to counteract the influence of 
any etiological factors that may be under our control. Orna- 
ments must be removed from the auricular lobe and their re- 
placement positively forbidden; the drum membrane must be 
examined for perforations and, if any are disclosed, they must 
receive proper attention; suppuration must be appropriately 
treated and even when there is no discharge of pus the meatus 
must be kept sound and clean by daily irrigation with a satu- 
rated solution of boric acid, followed by drying with a cotton- 
tipped applicator. The rhagades, which are apt to be found 
behind the auricle, where the inflamed skin has been wounded 
by rough handling, must be cleansed and dried with great 
gentleness and touched with a solution of silver nitrate of a 
strength of sixty grains to the fluidounce and then dusted 
with pulverized boric acid. Crusts and scabs when loose, are 
lifted with dressing forceps; if adherent they are covered 
with ointment of zinc oxide, which is left on over night; in the 
morning they will be much softened and are easily removed; 
the denuded surface, if there are vestiges of pus, is cleansed 



THE EXTERNAL EAR 335 

with a cotton swab steeped in a mixture of hydrogen peroxide 
and water, its strength being sufficient to decompose all pus 
but not sufficient to check granulation, which it is our purpose 
to encourage. The clean surface is then dusted with a powder 
made of equal parts of zinc oxide and boric acid. When great 
discomfort is caused by the pruritus the skin should be lightly 
rubbed with a powder made by mixing intimately twelve grains 
of pure phenol with one dram of calomel and three drams 
of talcum powder. In addition to the local treatment here 
advised, attention must be given to the general health. In- 
discretions in eating and drinking must be avoided with sedu- 
lous care, and even greater watchfulness must be practised to 
prevent constipation which in many persons greatly aggra- 
vates the symptoms. Some patients are benefited by the 
exhibition of the alkalies, particularly the salts of potassium 
and strontium, and others derive advantage from iron, prob- 
ably through its influence upon the red corpuscles of the 
blood. There is a form of dermatitis, symptomatically identical 
with eczema erythematosum, which follows continuous use of 
iodoform, in persons who have an idiosyncrasy regarding 
the iodine compounds. It disappears in a variable time after 
withdrawal of the medicine and should any effects persist, 
they must be treated as though sequels of the idiopathic 
affection. 

Furunculosis occasionally occurs at the orifice of the meatus 
originating in the follicles of the hairs, which are in some persons 
very abundant at that place, and causing redness, heat and 
tenderness. If the morbid process is only slightly advanced, 
so that resolution is possible, a cure can be effected by in- 
troducing, apex first, a conical plug of cotton smeared with 
this ointment: 

1$. Hydrarg. oxidi flavi gr. ij 

Adipis Ian re hydrosi (lanoline) 5iij 

Misce et fac unguentum. 

If morbid action has gone far enough to cause pustulation 
in some of the follicles, the hairs must be extracted from 



336 NOSE, THROAT AND EAR 

those thus affected and the pus evacuated. If a little purulent 
fluid remains, keeping up irritation, it may be readily de- 
composed by injecting with a blunted hypodermic needle a 
drop of hydrogen peroxide by way of the vagina pili, emptied 
by the extraction of the hair. 

Herpes of the auricle is a rare disease and the severe neuralgic 
pains which accompany it may be attributed to something 
else; but close inspection of the vesicular eruption will establish 
the diagnosis. The cutaneous lesions are the same as in 
herpes zoster and the neural pathology is similar. The con- 
stitutional treatment applicable to the more common form of 
the affection should be followed in the auricular variety. 
Topical measures are palliative and do not shorten the course 
of the disease, but they lessen the patient's discomfort. Sed- 
ative lotions and ointments may be applied over the affected 
skin and small hypodermic injections of morphia may be 
required during exacerbations of the neuralgia. 

Perichondritis is an inflammation of the membrane which 
coders the cartilage and separates it from the skin. It may 
affect any part of the auricle except the lobe, but the tragus is 
most frequently involved. Its etiology includes traumatism 
(often the parental cuffing and wrenching already referred to) 
and extension of morbid action from adjacent parts, par- 
ticularly the meatus. The lobe being destitute of cartilage is 
exempt. The disease begins with congestion of the peri- 
chondrium, signified by vivid redness of the overlying skin 
and by great tenderness. As soon as serous effusion takes 
place, swelling supervenes, often to an extent which alters 
the contour of the affected part, and the coincident pressure 
causes acute pain. With the formation of pus occur the 
familiar symptoms, general and local, associated with pyo- 
genesis. If "left to nature" perichondritis tends to spon- 
taneous recovery, ulcerative perforation of the skin causing 
the formation of a sinus, or more commonly several, through 
which the pus is gradually discharged, and cicatrices ultimately 
close the openings. These so-called "natural cures" are very 



THE EXTERNAL EAR 337 

unsatisfactory. The patient suffers much and long from a 
running sore, incurs the risk of the spread of purulent infec- 
tion and finally has auricular deformity more disfiguring than 
the knife's worst results. 

If treatment is instituted at the very start, the congestion 
may be overcome by the auricular bag of crushed ice, aided by 
the administration of saline purgatives and aconite. When 
effusion has taken place the liquid must be withdrawn. The 
use of the aspirator, supposedly scarless, is a concession to 
the fears of a patient who thinks the knife will disfigure her 
ear and if we are sure that the pulsating liquid is serum only, 
aspiration is justifiable: there are reports of both its success 
and its failure. When pus is present in perichondritis the 
aspirator does not remove it thoroughly. This is the consensus 
of opinion and there should be no delay in penetrating the 
cavity by an incision large enough to insure complete evacua- 
tion of all the contents. Subsequent treatment should be 
that required by any pyogenic cavity. Curettement is needed 
in cases of delayed healing and in every instance aseptic con- 
ditions of the incision and the surrounding parts must be 
maintained by a light, sterile dressing, which protects the 
auricle without exerting any pressure. 

An othematoma is a tumor caused by extravasation of 
blood between the perichondrium and the cartilage of the 
auricle, where it appears as a fluctuating mass of convex shape 
and bluish color. It is nearly always of traumatic origin 
and may complicate an attack of perichondritis ; but there are ex- 
ceptional cases lacking such causation, in which the othaematoma 
may possibly be due to some lesion in the nerve centers. When 
the tumor is of a noninflammatory character, absorption may 
be induced by daily paintings with tincture of iodine, massage 
and a dressing making moderate pressure. The failure of 
these measures after fair trial is an indication for subjecting 
the tumor to the operation performed upon the haematomata 
in other parts of the body. An incision is made to allow 
the evacuation of the contents, the lining of the cavity is irri- 



338 NOSE, THROAT AND EAR 

gated antiseptically and the opposite surfaces are coaptated 
and held in place by an efficient dressing until they unite. 
Patients should be warned that some disfigurement is liable 
to remain despite the best treatment; for the auricle may be 
affected with chondromalacia making the cartilage so soft and 
weak that it cannot be retained in the normal position during 
the healing process. 

Abscesses developing in the course of an attack of peri- 
chondritis are merely local exaggerations of processes occur- 
ring during the purulent stage of the disease and should be 
treated accordingly. 

Otitis externa diffusa is an inflammation of the lining mem- 
brane of the external auditory meatus and has the usual 
symptoms: heat, redness, swelling and pain. The tumefac- 
tion is often marked and renders examination with the speculum 
quite difficult; this feature also affects the movements of 
the lower jaw, as the muscles are stiffened by the surrounding 
infiltration and motion becomes painful, so that the patient 
is reluctant to take food which requires chewing; aside from 
this source of pain, the disease is attended with considerable 
suffering which may require the administration of sedatives. 
The hearing may or may not be dulled by the encroachment 
of the swelling upon the lumen of the meatus; but it is de- 
cidedly affected, when the cutaneous layer of the drum-head 
becomes involved, as it does in nearly half the cases. This 
form of otitis is caused by the bacillus pyocyaneus whose 
presence is demonstrable by bacteriologic tests. There is also 
a peculiar feature in this inflammation which aids in distin- 
guishing it from those produced in other ways; this peculi- 
arity is the absence of pus; the other phlegmonous symptoms 
are present and frequently severe, but pus is not exuded spon- 
taneously nor is it brought to light by an incision. The 
etiologic germ appears to have the power of repelling the 
leukocytes so that the usual process of inflammation stops 
short of purulent effusion. The disease commonly terminates 
spontaneously in three or four weeks but is apt to recur. 



THE EXTERNAL EAR 



339 



The most efficient remedy is a five per cent, solution of silver 
nitrate which, acting as a germicide, extirpates the cause of 
the disease, and also by its causticity promotes exfoliation of 
devitalized tissue. The application should be made with a 
cotton-tipped probe to the diseased surface and repeated, at 
intervals, until desquamation is complete. 

Otitis externa crouposa has the same etiology as the variety 
just described, from which it differs in producing a pseudo- 
membrane covering the interior of the meatus ; the envelopment 





Fig. i 



Otomycosis. 



Greatly enlarged illustration of fungus, aspergillus niger. 
{Knight and Bryant.) 



may be partial or complete and sometimes this sheath is cast 
off in a single piece, having the shape of a glove finger. The 
treatment with silver nitrate is applicable to this variety as well 
as to otitis diffusa. 

Otomycosis, accurately portrayed in Fig. 108, is another 
disease of bacterial origin. It is generally unilateral. A 
microscopic fungus, or mould, develops upon the lining 
membrane of the meatus, at first giving rise to few symptoms 
but when it has encroached much upon the canal, causing parox- 
ysms of pain and impairing the hearing. Through the specu- 
lum the walls of the canal show a deposit of scales and flakes of 
a grayish-yellow color sprinkled with black specks. The 



340 NOSE, THROAT AND EAR 

growth of fungi is favored by previous disease and by lack of 
cleanliness, subjecting the aural membranes to the combined 
influences of heat, dirt and dampness. When oil has been in- 
stilled into the meatus and subsequent cleansing neglected, its 
remains become a soil most friendly to implanted bacteria. 
Doubtless, impairment of the general health, by lessening the 
resisting power of the epidermis, promotes the implantation of 
these germs which, under normal conditions, would be cast off 
as soon as they were deposited upon the surface of the skin. 
Cases of otomycosis, when seen by the physician, are generally 
at an advanced stage and the congestion and tenderness of the 
canal call for sedative treatment. A saturated solution of 
boric acid may be used for daily irrigation and its application 
followed by insufflation with powdered zinc oxide. When some 
amelioration of the symptoms has been secured the fungus 
should be destroyed by an active germicide. The remedy 
which I prefer is a two per cent, alcoholic solution of salicylic 
acid instilled drop by drop into the affected meatus, the patient 
being in the recumbent posture on the other side. Enough of 
the solution should be used to thoroughly moisten the scaly 
layer within the canal, and upon the following day the loosened 
particles should be washed away by a jet from the syringe. 
Then another layer should be saturated and when loosened 
removed in the same way, the treatment being continued until 
the meatus is entirely free from the fungus. 

Erysipelas sometimes appears primarily in the auricle, the 
streptococcus gaining a lodgment in some fissure or excoria- 
tion, though it is more frequently an extension of the facial form 
of the disease; the meatus is often involved and sometimes the 
membrana tympani; but intracranial infection is rare. Rest 
and aseptic surroundings are important as they are when the 
disease affects other localities, and the internal administration 
of the tincture of iron chloride, ten minims every three hours, 
has long retained the confidence of the profession. Topical 
use may be made of folded gauze steeped in lead water and 
laudanum, or in a twenty per cent, solution of magnesium 



THE EXTERNAL EAR 341 

sulphate. Obstinate cases and those showing a disposition to 
recur should be treated with antistreptococcic serum. 

Malignant growths upon the external ear are rare and those 
reported have been remarkable for amenability to treatment, 
indeed such neoplasms have a better prognosis in this locality 
than in any other part of the body. Their site is commonly 
the tragus, whence they extend to the concha, antitragus and 
meatus, for a long time sparing themembrana tympani, though 
this is ultimately involved. Like other cancers, they are gen- 
erally seen in persons past fifty years of age, but in several re- 
corded instances the patients were under twenty. Bezold made 
a study of a group of these cases, arriving at results which are 
surprising and almost paradoxical. The neoplasms were classi- 
fied as sarcomata and epitheliomata, because repeated micro- 
scopic examinations left no doubt as to their morbid anatomy. 
They gave rise to frequent and severe pain and bled when sub- 
jected to slight irritation, or even spontaneously. So far they 
conformed to the description of malignancy which is so familiar; 
but their other features exhibited contrasts rather than simi- 
larities. Their growth was exceedingly slow, extending over 
years ; in very few instances was there any involvement of the 
cervical or other glands and in none was a cachexia developed. 
In some of them treated with the Roentgen rays, there were 
long periods of quiescence, during which part of the ulcerated 
area was recovered by skin of normal character. Most sur- 
prising of all was the result of operation. In cases where it 
was possible to remove the growth together with a marginal 
segment of healthy tissue, excision was performed and in all 
these cases the patients were apparently cured. During in- 
tervals ranging from three to five years, which elapsed be- 
tween the operations and the publication of the statistics, there 
were no recurrences. Making every allowance for exceptional 
circumstances which may have affected results in this group 
of cases, they still show that cancer is not necessarily beyond 
remedy and that we may hope to find a curative treatment for 
malignant disease. 



342 NOSE, THROAT AND EAR 

The actual size reproductions given in Fig. 109 are posterior 
and lateral views of the same auricle. It will be observed that 
the disease has wholly destroyed the tragus and antitragus 
together with much of the skin and subjacent tissues along the 
line of junction of the auricle with the mastoid surface, leaving 
an elliptical opening three-fourths of an inch long. A probe 
has been passed through this hole and the notch left by destruc- 
tion of the tragus. The patient was a widow, sixty-one years 
of age with good family history and no recollection of any im- 
pairment of hearing or any affection of the nose, throat or ear, 
until five years ago, when a tumor appeared in the auriculo- 
mastoid crease and continued to grow slowly and without 
ulceration for six months. The growth was extirpated. Post- 
operative healing was rapid and complete, patient remained 
well for three years, then a blow upon the auricle from a falling 
chair started a tumor at site of former growth. It developed 
its present condition in sixteen months. Pathological report, 
''carcinoma." 

European otologists make mention of a dangerous inflamma- 
tion and necrosis of the external and middle ear voluntarily 
induced by conscipts who pour corrosive liquids, like the strong 
mineral acids, into the meatus, expecting that the damage done 
to their hearing will render them exempt from military service. 
Their folly sometimes leads to fatal consequences and the facts 
brought to light by legal investigation prove that this perni- 
cious practice is not infrequent. It is strange that any sane 
man should choose such a dreadful alternative rather than serve 
a term of enlistment, and it is disgraceful that regular physicians, 
graduates of the universities, should, for a small fee, take part 
in this shameful malpractice, but that also is beyond question. 
Jiirgens reports that four young men, who had been con- 
scripted in Warsaw, poured strong hydrochloric acid into their 
ears to cause their rejection by the examining surgeon. In 
agonizing pain they were taken to a hospital. One died of 
haemorrhage, two of meningitis and the fourth survived, deaf 
and partially paralyzed. 




(Facing page 342.) 



THE EXTERNAL EAR 343 

This pernicious practice seems to be unknown in the United 
States. It is true that during the conscription in the latter part 
of the civil war, some drafted men sought exemption by simu- 
lating deafness, but their plan was to deceive the examiner, not 
to injure their ears, and there is no report of any self-inflicted 
damage comparable to the cases above cited. 



CHAPTER XXX 
MIDDLE EAR: TUBAL OBSTRUCTION 

The middle ear, comprising the tympanum, Eustachian tube 
and mastoid sinuses (Chapter XXVII) , is a complex structure and 
has certain anatomical features found in no other part of the 
body. These peculiarities are only partially revealed by dis- 
section, but become obvious in the light of pathological proc- 
esses. For example the course of what has been called catarrh 
of the middle ear is different from the course of catarrhal in- 
flammation elsewhere; indeed the order of phenomena is nearly 
reversed, a fact due to histologic differences. The effort to 
classify morbid processes, as modified by these unusual struc- 
tural features, has led to much diversity in the nomenclature 
of middle-ear diseases as given by the text books in common 
use. 

I believe the otologists of the Munich school are right in 
teaching, that under the influence of disease the lining of the 
cartilaginous section of the Eustachian tube acts in a manner 
similar to that of mucous membranes elsewhere, while the 
lining of the rest of the tube, of the tympanum and of the mastoid 
sinuses behaves more like a serous membrane; so that the isth- 
mus becomes a demarcation, with morbid manifestations of a 
certain kind on one side, and of a different kind upon the other. 
Viewed in this way, the processes of disease are more readily 
understood and are separated into those which at the start 
are inflammatory, and those which are not. 

Diseases of the middle ear are very frequent, constituting two- 
thirds of all aural maladies. This prevalence is due in part to 
the duality above mentioned and in part to the great frequency 
with which the exanthemata of childhood affect the tube, 
tympanum and sinuses. In a majority of cases, these infections 

344 



MIDDLE EAR: TUBAL OBSTRUCTION 345 

invade some part of the middle ear, though often the involve- 
ment is slight and temporary. 

Tubal obstruction frequently exists for a considerable time, 
without attracting attention, until it is disclosed by an ex- 
amination undertaken to discover the cause of incipient deaf- 
ness. In other cases it manifests its presence by discomfort 
and even pain. As seen by the physician it has usually existed 
a good while and is accompanied by inflammation, but this 
coincidence is not a necessary association and it is important 
to ascertain which of the two conditions stood first in the order 
of time, for in this matter, post hoc is also propter hoc. It is 
true that chronic inflammation gives rise to obstruction, but 
there are obstructions in whose causation inflammation plays 
no part and if they are seen at an early stage, before there is 
much interference with drainage and ventilation, they exhibit 
simple intrusions upon the lumen of the tube, with variations 
in degree from slight encroachment to remittent occlusion. 
This type of obstruction is more common than is generally 
supposed, because secondary or concurrent affections of ten divert 
attention from the primary disease. According to Bezold's 
statistics, more than eight per cent, of cases of impaired hearing 
have this form of obstruction among their etiologic factors. 

The fact recorded by many observers that this condition 
is far more common in children than in adults, would lead us to 
suspect that its origin might be lymphomatous and this de- 
duction is borne out by examination with the finger and the 
posterior rhinoscope. Adenoids hold the chief place in causa- 
tion and, as we should expect, both tubes are usually affected. 
Adenoids, fully considered in Chapter XV, produce obstruction 
in two ways. By exuberant growth close to the tubal orifice 
they press upon the Eustachian lips, which are hampered more 
and more, until deglutition, instead of habitually opening the 
aperture, does so only occasionally (remittent occlusion). In 
this case the result is due to simple, mechanical pressure and 
that alone. The other type of adenoid obstruction is due to 
lymphoid growths beneath the lining membrane of the carti- 



346 NOSE, THROAT AND EAR 

laginous portion of the tube, gradually encroaching upon its 
lumen. Here, too, the phenomenon is one of pressure but there 
is also another feature. The protrusions from the tubal wall 
may cause increased rugosity of the surface and thus contribute 
to the hindrance of drainage. In addition, the effect produced 
is necessarily constant, not remittent, as was possible in the 
other case. 

In the instances just considered, the mechanism of tubal ob- 
struction is very plain, but in others it is less simple. We find 
occlusion when there is no obvious abnormality in the area 
close to the orifices and may erroneously conclude that we are 
dealing with the sequel of some antecedent inflammation. Such 
a condition should prompt us to investigate carefully the state 
of the structures further away from the tubal apertures. If 
we find tumors or marked hypertrophies, it is likely they are 
responsible for the obstruction, because they act as brakes upon 
the muscles whose action renders the apertures patulous, so that 
opening is much hindered or entirely prevented. Hypertrophy 
of the faucial tonsil is often responsible for obstruction, as is 
proved by restoration of tubal patency after tonsillectomy; and 
great enlargement of the posterior ends of the turbinals is 
another cause. Tumors, traumata and cicatrices are all 
occasionally etiologic factors, producing morbid alterations 
in the musculomembranous framework of the naso-pharynx 
and interfering with the position and interaction of its parts. 
Closely allied to these effects are those produced by ulceration, 
tubercular, syphilitic and sometimes diphtheritic and variolous. 
The clinical picture in all these cases is one of damage to the 
tissues, lessening their elasticity and motility and impairing 
their functions. In atrophic rhinitis, thick crusts often form 
near the posterior orifices of the nares and extend backward into 
the naso-pharynx. When so situated, they may close the tubal 
apertures causing atresia until they are dislodged. The con- 
genital deformity of cleft palate is nearly always associated with 
tubal obstruction, partial or complete. 

The pathological phenomena consequent upon interference 



MIDDLE EAR: TUBAL OBSTRUCTION 347 

with the Eustachian functions can be recounted deductively 
for they are the reversals of physiological processes and the 
clinical history corroborates such a presentment. As has 
been observed, the tympanum resembles a serous cavity, hence 
in a normal condition there is some drainage of serum through 
the tubes. When they are occluded this serum accumulates 
first in the tubes themselves, under the influence of gravity, 
and then in the tympana where it slowly undergoes a physical 
and chemical change. At the same time the air in the chamber, 
incarcerated because there is no ventilation, gradually dis- 
appears, its oxygen probably uniting with the serum whose 
alteration is catabolic in character and its nitrogen being 
absorbed by the lining membrane. As the air lessens in 
quantity, the membrana tympani is pushed inward, presenting 
a concave surface at the lower end of the external meatus. 
Later on this retraction is followed by collapse and sometimes 
by atrophy. 

These varied morbid changes are not inflammatory, but 
by reducing the vitality of the tissues and favoring the re- 
tention of retrograde products, they supply conditions favor- 
able to the development of inflammation, and this often occurs 
as an intercurrent disease, when obstruction of the tubes is 
neglected and "left to nature." It is a morbid state replete 
with probabilities of untoward results, but also very amenable 
to therapeutic measures intelligently and skilfully pursued. 

In this affection impairment of hearing is, in some degree, 
due to the occlusion per se but far more to the damage inflicted 
upon the tympanum, and a prime object is to prevent its 
further injury and to repair what has already been done. 
Treatment is therefore addressed both to the elimination of 
the causes and to the restoration of the structures which 
have suffered detriment. When the tubal orifice is closed by 
the direct pressure of contiguous adenoids, the growths must 
be extirpated (see operation in Chapter XV) and it will be found 
in many cases that their removal will bring about the dis- 
appearance of minor adventitious growths which yield to 



348 NOSE, THROAT AND EAR 

the restored activity of the absorbents. When the trouble is 
due to hypertrophic extension of the turbinals into the naso- 
pharynx, the superfluous tissue must be removed by opera- 
tion. The same advice applies to the faucial tonsils when 
they are the cause of occlusion. I have already (Chapter XIX) 
expressed my aversion to half-way measures in dealing with 
hypertrophied tonsils. Tonsillectomy, skilfully performed 
and followed by proper care during postoperative convales- 
cence, is safe and efficient treatment and yields the best results. 
Tumors and cicatrices give rise to conditions of such varied 
character that treatment must, of necessity, be individualized. 
The extirpation of neoplasms and the cutting of adhesions 
which embarrass muscular action may restore the Eustachian 
orifice to a patulous condition; but in determining what meas- 
ure to take, consideration must be given to all the results of 
operative interference upon the pharyngeal structures and 
functions. When rhinitis in any form plays a part in caus- 
ing occlusion, that disease should be subjected to active and 
persistent treatment (Chapter VII)., 

Adenoid growths subjacent to the lining membrane of 
the tube are confined to the portion below the isthmus and 
their encroachment, while decreasing the lumen, very rarely 
goes far enough to produce occlusion. They are not sus- 
ceptible to excision, but can usually be considerably reduced 
by medicinal applications so that their obstructive influence 
becomes slight. I am accustomed to begin treatment with 
an eight per cent, solution of tannic acid in glycerine carried 
to the constricted part of the tube by a cotton-tipped applicator 
which has been conformed to the shape of a Eustachian cath- 
eter. This should be used several times and if it prove in- 
efficient should be replaced by a two to five per cent, solution 
of ethylmorphine hydrochlorate (dionin) in distilled water 
applied in the same way. Most cases will be benefited by 
this treatment. When the condition is obstinate, careful dila- 
tion with bougies may be practised, or absorption induced by 
electrolysis. In this procedure use is made of a thirty- to fifty- 



MIDDLE EAR: TUBAL OBSTRUCTION 349 

volt battery and a current of from one to five milliamperes is 
passed through the thickened part of the tubal wall by means 
of an insulated bougie having an olive-shaped head of gold 
which rests against the constriction and is connected with the 
negative pole, while the positive electrode is held in the patient's 
hands. 1 

If tubal obstructions have been removed and, in conse- 
quence, drainage and ventilation reestablished, there remains 
the therapeutic task of restoring the tympanum to its normal 
anatomical condition and of reviving functional powers 
paired during the period of occlusion. 2 

The retracted or collapsed drum-head can be reinvigorated 
by inflation of the tympanum with the Politzer air bag. The 
success attained greatly depends upon good judgment in 
carrying out this simple procedure with proper force and 
frequency. The purpose in view may also be promoted by 
treating the membrane upon its outer side with Siegle's oto- 
scope and Delstanche's masseur (Chapter III, Armamenta) and 
an alterative influence can be exerted upon the debilitated 
membrane's nutrition by inunctions of mercury applied upon 
its exterior surface in the form of an ointment containing five 
grains of the yellow oxide in an ounce of petrolatum. These 
measures generally succeed in restoring the auditory con- 
ducting power to a large extent and sometimes, when the 
morbid changes have been speedily corrected, to a condition 
altogether normal. 

1 There is a striking contrast between the Eustachian tube and the other canal, 
with which comparison is naturally suggested by its similar liability to obstruc- 
tion, viz.: the male urethra. Urethral strictures are common but their site is 
nearly always some point in the course of the passageway, scarcely ever at either 
the vesical or penial orifice; an exact reversal of what is observed in the Eusta- 
chian tube, in which occlusion is most common near one of the ends. 

2 In some cases, before the reopening of the tubes has been effected, the in- 
carcerated serum, either on account of excessive quantity or degenerative change 
in its character, must be evacuated and myringotomy becomes necessary; but 
these instances are exceptional and description of the operation is deferred to the 
discussion of otitis media, in which it is often required. 



CHAPTER XXXI 
SIMPLE OTITIS MEDIA: ACUTE AND CHRONIC 

Nonsuppurative or Catarrhal Otitis Media 

The morbid conditions of the middle ear so far considered 
have depended primarily upon tubal obstruction, however varied 
have been their secondary manifestations. We now pass to 
those whose common characteristic is inflammation, originat- 
ing in different ways and developing in protean forms. Diseases 
of this kind are so numerous that if they were all eliminated 
there would remain little more than a third part of present 
otologic practice. The majority originate from pathogenic 
germs, conspicuous among which are the pneumococcus and 
the streptococcus pyogenes; the staphylococcus pyogenes also 
is frequently an etiologic factor, though most often associated 
with the late rather than the early stages of inflammation. A 
distinction between these affections and those of mechanical 
origin arises from the anatomical differences between the lining 
membrane of the tympanum and that of the Eustachian tube, 
where the obstructive lesions originate. The lower section of 
the canal is comparatively capacious and, as its orifice is near 
the junction of the breath-road and food-road, it is exposed 
to the action of the varied substances traversing each of these 
passages, whether they be organic or inorganic, the former in- 
cluding the micro-organisms of all kinds; hence the tubal 
mucosa acquires a tolerance of their presence and becomes fitted 
to neutralize their nosogenic influence, providing its normal 
mobility and proper circulation be not hampered by obstruc- 
tion. On the contrary, the tympanum is normally an aseptic 
cavity defended on all sides from hostile intrusion, and its 
lining membrane exhibits the vulnerability characteristic of 



SIMPLE OTITIS MEDIA 35 1 

serous tissues. If the fortifications are broken through, the 
invaders encounter little resistance in the cavity itself and its 
minute dimensions make difficult the task of therapeutic re- 
inforcement. The result is that we can do comparatively little 
to antagonize tympanic inflammations by topical measures 
within the cavity, as contrasted with what we can accomplish 
by reconquering and holding the outer defenses and by modify- 
ing the vital processes of the whole organism in a way to 
diminish the virulency of the toxic attack. 

On account of the peculiarly rapid histogenetic changes oc- 
curring in the aural region during the first two or three years of 
life, the acute diseases of infancy are very apt to affect the 
middle ear to a greater or less degree; the extent to which the 
tympanum is involved varying from a slight congestion to a 
suppurative otitis. The mild cases greatly preponderate in 
number and, barring some special complication, spontaneous 
recovery accompanies convalescence from the systemic malady 
and no permanent sequels remain, the rapid metamorphosis of 
tissue promoting a return to normal conditions as, under the 
influence of a general morbidity, it had assisted in extending 
the disease. 

Under the title Simple Otitis Media: Acute and Chronic, I 
include those cases of congestion and inflammation of the middle 
ear, howsoever produced, which are not accompanied by sup- 
puration. The classification is symptomatic rather than 
etiologic, but is adopted on account of its great convenience. 
Subsequent to the period of infancy, this form of otitis has two 
causes, which give rise to the great majority of cases, and both 
causes nearly always act in a secondary or intermediate way. 
The first is coryza, 1 or "catching cold," the second the group of 
infectious fevers. In that morbid process called coryza, so 
exceedingly common in our variable climate, the ear is often 
affected, but always secondarily; at least, I have never seen it 

1 Coryza is specified separately from the infectious diseases, because of un- 
certainty regarding its etiology, a matter which is fully considered in Chapter 
VII. 



352 NOSE, THROAT AND EAR 

the subject of a primary attack. The nasopharynx shows 
inflammatory manifestations which the practiced eye will recog- 
nize as antecedent to any presented by the tube and tympanum. 
Moreover, the rational symptoms point to the throat and nose 
as being first affected. In the infectious fevers, the same state- 
ments hold good. A posterior rhinoscopic examination will 
prove that the naso-pharynx is involved, often to a marked de- 
gree, at the inauguration of the tympanic trouble. There can 
be no doubt that in a great majority of instances the ear is 
affected, not through the sanguineous or lymphatic circulation, 
but simply and wholly by an extension of the morbid process 
into the Eustachian tube and through it into the tympanum, 
such extension being facilitated by the continuity of the lining 
membrane from the aperture of the tube to the interior of the 
tympanum. 

While simple otitis media usually originates in these ways, 
there are certain other causes to be mentioned. Tubal occlusion 
(Chapter XXX) if long continued, or recurring very frequently, 
may set up inflammation and the same result may follow trau- 
matism of the drum-head. There are also two artificial ex- 
citants for which pharyngology is responsible. The use of the 
galvanocautery in the nose and throat has produced otitis in 
a number of instances, as has also the tight tamponing of the 
naso-pharynx, when the packing was retained for a considerable 
time. It is possible that these untoward results give no just 
grounds for criticism of the operator; for the conditions de- 
manding the cautery and the tampon may have been of such an 
urgent nature that he would have been justified in using them 
even if certain that otitis would follow. Often a dilemma com- 
pels a surgeon to choose the lesser of two evils and this is a 
truth which must ever be remembered in judging the work 
of our colleagues but, nevertheless, it is essential to know 
that the galvanocautery requires great caution in its use and 
can never be classed among the things which are safe for routine 
employment. The tampon also has its dangers, though it 
appears so harmless both in the material of which it consists and 



SIMPLE OTITIS MEDIA 353 

in the method of its application. When inserted firmly, it 
greatly constricts the blood vessels, producing venous stasis 
in the area of direct pressure and passive congestion in near-by 
tissues; so the time of its retention should be as brief as 
will accomplish the purpose for which it was used and it should 
not be introduced by one man, with the view to its removal 
by another who succeeds him on duty, a dangerous practice 
sometimes seen in dispensaries. It is a useful appliance, but 
never wholly devoid of danger till removed. 

Cold bathing has long been counted among the habits 
injurious to the hearing. The older writers attributed the 
harm done to the shock caused by sudden lowering of tem- 
perature and this doubtless affects some persons, though 
many escape. The influence of thermic changes, like that of 
others, is modified by individual characteristics. There is 
another way in which those addicted to cold bathing may suffer 
aural injury, a way seldom, if ever, mentioned in books. Many 
persons prefer a plunge into a lake, stream, or even pond, as 
more pleasurable than immersion in a bath tub, unmindful of 
the fact that the water in streams and especially ponds is 
often contaminated in many ways, and the active muscular 
movements of outdoor bathers bring much water into the 
naso-pharynx, whence it may enter the tympanum through the 
Eustachian tube and deposit its impurities where they have 
every opportunity to do harm. Pure sea water with its saline 
content is usually a beneficial wash for the mucous membrane, 
but the water upon the beaches of the large seashore cities is 
not always pure. It often has an admixture of sewage and 
always carries during bathing hours the varied dermal ex- 
cretions of the throngs, healthy and diseased, disporting in 
the surf. The proportion of injurious, organic matter in 
such water is small; but a few particles of toxic character are 
quite sufficient to affect a susceptible membrane like that 
which fines the middle ear. The thousands who make merry 
in the surf are in very active motion, many of them shouting 
and laughing. They imbibe a great deal of water and, in 



354 NOSE, THROAT AND EAR 

swallowing, open the lower apertures of the tubes so that it 
is very easy for some of the water to find its way into the 
tympana and, if it carries the washed off detritus of tubercular 
or syphilitic sores, or some virulent cells from a dripping 
gonorrhoea, the bather may have serious cause to regret his 
sport in the "joyous, health-giving breakers of old ocean." 

There is another practice which has caused more middle- 
ear disease than the various forms of outdoor bathing. I 
refer to the gravity nasal douche which sends a stream of 
water into one nostril to escape by way of the other. Half a 
century ago this little instrument came into general use by 
the recommendation of physicians who regarded it as a safe 
and efficient cleanser of the nasal passages. The douche was 
simply a glass vessel shaped somewhat like a slipper with a 
small orifice at the narrow end (the toe) and a larger one at 
the top, the latter used for filling the chamber and the former 
for insertion into the nostril. It was easily manufactured at a 
trifling cost and yielded to the seller even when marketed at a 
small price, a profit of several hundred per cent. It became 
popular with the laity and in a few years the sales reached 
a nearly incredible figure. After a time it was observed that 
many persons habitually using the douche contracted disease of 
the middle ear and comparisons of experiences by otologists 
put beyond question the fact that the douche was an etio- 
logic factor in otitis media. Professional opinion soon came 
to discourage its use, but wholly upon empirical grounds; for 
why it did harm was not then understood. The development 
of bacteriology shed a clear light upon the nosogenic process 
and it became plain that infectious germs borne by the water 
into the naso-pharynx found entrance to the Eustachian tube 
and thence to the tympanum. The use of the douche by the 
laity is now wholly discountenanced among physicians and 
its employment even in tainted hands is restricted to a few con- 
ditions and in these cases care is taken that the tubes shall 
be fully safeguarded. The amount of otitis due to the douche 
has greatly diminished in recent years but there are still 



SIMPLE OTITIS MEDIA 355 

attacks referable to this cause, the patients having gener- 
ally used the instrument as inexpensive home treatment, upon 
the advice of friends and neighbors. 

The symptoms of otitis in its first stage are often masked 
by those referable to some acute general disease which is co- 
existent. Pain is the most frequent subjective sign and its 
presence in the aural region has much diagnostic significance, 
for there is little explanation for it, aside from disease of the 
ear. The first morbid sensation is commonly a sense of ful- 
ness, "stuffiness," in the throat and ear upon one side, accom- 
panied by some stiffness of the muscles. These phenomena 
are coincident with the onset of congestion in the naso-pharynx 
and Eustachian tube and are soon followed by acute pain in 
the tympanic region, often seeming to radiate from the ex- 
ternal auditory meatus and commonly growing worse in the 
evening. The severity of this pain depends upon the gravity 
of the disease, but even more upon the neural susceptibility 
of the patient and ranges from intermittent twinges to con- 
stant suffering so great as to call for the hypodermic injec- 
tion of a sixth or fourth of a grain of morphine. The clinical 
thermometer registers some increase in the temperature of 
the body but this, unless influenced by a coexisting con- 
stitutional malady, seldom exceeds 2° or 3 F. An excep- 
tion must be noted in regard to children, in whom the 
elevation may rapidly reach 104 or 105 ° F. Their great 
susceptibility in this respect explains the fact and on this 
account marked thermic changes have in children far less 
significance than in adults. 

Upon inspection with the aural speculum, the membrana 
tympani is found much reddened and lacking its normal 
pearly luster. It may be either pushed in or bulging, the 
former condition indicating a rarefaction of the intratympanic 
air and the latter an accumulation of serum. There is usu- 
ally a quite noticeable impairment of hearing in the affected 
ear, particularly affecting tones of low pitch and readily tested 
by tuning forks standardized for from 100 to 256 V.D. This 



356 NOSE, THROAT AND EAR 

surdity is annoying to the patient but frequently he has a 
much more distressing symptom in the onset of tinnitus aurium. 
This subjective sensation, due to hyperesthesia within the 
tympanum and to alterations in the normal posture of the 
ossicles, simulates a great variety of objective sounds and 
these are iterated and reiterated until the annoyance at first 
produced becomes exasperation. They "get on the patient's 
nerves," in both a literal and metaphorical sense and some 
neurotic sufferers have been made so desperate that they have 
sought the advice of charlatans who promised them relief, and 
have in consequence incurred permanent injury as the result of 
operations upon the drum-head and ossicles, to put an end 
to the tinnitus. If the physician can gain the full confidence 
of such patients, he can render them a very great service by 
assuring them that this symptom is nearly always dependent 
on conditions which are curable and that resolute endurance 
for a brief time will almost certainly be rewarded by its dis- 
appearance. He should, of course, meanwhile employ such 
palliative measures as can be used without damaging the 
tympanic structures. In favorable, uncomplicated cases the 
acute attack terminates by resolution in a few days and rarely 
continues more than one or two weeks. These satisfactory 
results are sometimes spontaneous recoveries in patients 
who have had no treatment whatever, but such good fortune 
is by no means the rule. When left to nature, the disease tends 
to progress to suppuration, or to assume a chronic form char- 
acterized by sub-acute, nonsuppurative inflammation. This 
is a cogent reason for prompt and energetic therapeutic action 
and it is reinforced by the fact that such action proves, in a 
great majority of cases, fully curative. 

The treatment now approved by the consensus of professional 
opinion is based upon the etiology of the disease. We have seen 
that, with few exceptions, the complaint is secondary to affec- 
tions of the naso-pharynx and it is to these affections that our 
remedial efforts must be addressed. All morbid conditions in 
this cavity and the contiguous region must be fully investigated 



SIMPLE OTITIS MEDIA 357 

and their correction persistently sought in our scheme of thera- 
peutic procedure. Surgical operations, however, are to be 
postponed until acute inflammation has subsided. A thorough 
cleansing of the nasal and pharyngeal cavities is not only 
beneficial per se, but important as a preliminary to other 
measures. DobelPs solution should be sprayed through the 
nostrils to dislodge the coating of thick, tenacious mucus which 
i? commonly found in the posterior nares and naso-pharynx. 
If this prove insufficient, a pledget of cotton wound upon a 
flexible applicator should be saturated with the liquid and 
carried along the floor of the nose through the posterior orifice 
and there used as a mop to free the naso-pharynx from the layer 
of viscid secretions. If the tip of the applicator is bent to the 
shape seen in a Eustachian catheter, it will be efficient for dis- 
lodging the semi-solid plug often found occluding the aperture 
of the tube. 

In this, as in other acute inflammations, constitutional treat- 
ment is valuable, though it seldom does the good of which it is 
capable because patients are unwilling to interrupt their usual 
occupations on account of an illness which they consider of minor 
importance. There is great advantage in complete cessation of 
mental and physical work with rest in bed as long as there re- 
mains any elevation of temperature. Moderate purgation is to 
be secured with saline laxatives and, till convalescence, a milk 
diet should be directed with the withdrawal of alcoholic stimu- 
lants, tea, coffee and tobacco. When the pyrexia is marked, 
very good results follow the administration of tincture of acon- 
ite in small and frequent doses. Its relief of vascular tension is 
speedily followed by a fall in temperature and an amelioration 
of the pain quite as great as can be secured by remedies of the 
analgesic class. 

While our main reliance is upon such measures as have been 
enumerated, topical treatment has real value, chiefly in palliat- 
ing symptoms and warding off structural changes, until the 
attack has completed its clinical cycle. The rarefaction of the 
air within the tympanum, so frequently observed, logically sug- 



358 NOSE, THROAT AND EAR 

gests inflation of the cavity, as an obvious method of correction, 
and the advantage of this procedure has been fully established 
by experience. The Politzer air bag, either alone or in con- 
junction with the Eustachian catheter, is employed for this 
purpose (Chapter III). The impulse given to the column of 
air is at first very gentle, a slight, progressive increase of force 
being allowable at subsequent inflations, as the favorable effects of 
the treatment become manifest. These effects are watched by 
means of both the auscultation tube and the aural speculum. 
When the inflation accomplishes its purpose, we observe that 
the drum-head is no longer pushed in; the congestive redness is 
gradually replaced by the normal pearly luster, and the triangle 
of luminosity little by little recovers its brightness. At the 
same time there is improvement in the hearing and the tinnitus 
becomes less distressing and subject to periods of remission. 

Local applications of a palliative kind include the ice-bag or 
the hot-water bag over the mastoid region. One or the other 
usually affords the patient considerable relief; but whether heat 
or cold will do good depends almost entirely upon certain in- 
dividual traits. In the old systems of medicine these traits 
were recognized and classified as temperaments. The word 
with its qualifying adjectives has long disappeared from scientific 
treatises but is still retained in the common language; men still 
speak of the sanguine temperament, the lymphatic tempera- 
ment and three or four others. These popular terms, however 
unscientific they appear, convey a real meaning. In the matter 
under consideration, if the patient be of what is called the 
sanguine temperament, he will be benefited by cold, not by 
heat; if his temperament be lymphatic, heat will do good, while 
cold may aggravate his suffering. The use of morphine and of 
aconite in the control of pain has been already referred to. 
There is also a topical remedy whose value is attested by much 
experience in cases where the afferent nerves of the membrana 
tympani seem to be those chiefly affected. This is a ten per 
cent, solution of carbolic acid in glycerine. A few drops are 
instilled into the external auditory meatus, which has previously 



SIMPLE OTITIS MEDIA 359 

been cleansed of cerumen and other substances so as to give 
the best opportunity for absorption. The application of 
leeches, either living or mechanical, over the mastoid process of 
the temporal bone, I have not found necessary and I do not ap- 
prove the practice. My judgment is also averse to the use of the 
tincture or other preparations of iodine in the same locality. 

Simple otitis media in its chronic form, called also chronic 
catarrhal, and chronic nonsuppurative otitis media may be 
the continuation of an acute attack which has been intractable or, 
more often, which has failed to receive proper treatment. It 
may also from the beginning manifest the characteristics of a 
sub-acute, sluggish inflammation- — an extension of a similar 
process affecting the nose or pharynx. The tinnitus and other 
symptoms are much like those already described, subject to 
modifications .by the diminished activity and acquired tolerance 
which accompany chronicity. The partial deafness often ex- 
hibits a very peculiar quality. The patient when engaged in 
conversation with one person displays decided impairment of 
auditory power; but in the mingled noises of a crowd, where 
many persons are talking simultaneously, he hears better and 
is nearly on a par with a normal individual who is much em- 
barrassed by the confusion of sounds. So too amid the clatter 
of a mill or of a railroad train, this patient has relatively an 
advantage over a man with uninjured ears. This curious 
physiological paradox has been termed paracusis Willisiana. 
Such a patient, while striving to apprehend a dialogue whose 
words are uttered with more than ordinary force and distinct- 
ness, is liable to be startled by some shrill, high-pitched tone, 
suddenly impressing his audition with exaggerated force, a 
phenomenon called hyperesthesia acoustica. This experience 
may be surprising because of its disturbing intensity; but it is 
in accordance with the well-recognized fact that surdity depend- 
ent on damage to the conducting mechanism often causes little 
impairment of function for tones of high pitch which may even 
in some instances acquire abnormal distinctness. Coincident 
with the aural manifestations, attacks of vertigo occur in a con- 



3 6 ° 



NOSE, THROAT AND EAR 




siderable proportion of cases, apparently due to disturbance of 
the endolymph and perilymph of the semicircular canals. 

The physical signs include those alterations in the drum- 
head, which have been mentioned in describing affects of the 
acute attack, with the addition of others due to the prolonga- 
tion of the morbid process. The membrane is pushed in and 
has a congested, opaque and lusterless appearance. In time 
nutritive changes occur; they may be either hypertrophic or 
atrophic. In the one case there is more or less thickening and 
stiffening of the tissue; in the other, 
which is less common, the membrane 
becomes very thin, translucent and 
brittle, so that it is liable to fracture 
from very slight causes. A thin and 
semi-translucent membrane is shown 
in Fig. no. 

The affection of the middle ear 
may be accompanied by disease of 
the labyrinth, and the question of the 
presence or absence of such a compli- 
cation should be determined as defi- 
nitely as possible soon after the case 
has been undertaken; but certain 
measures of treatment necessary in 
either event may be inaugurated with- 
out waiting for a thoroughgoing test of the internal ear, 
for it is important on psychic as well as therapeutic grounds 
that something should be done for the patient at once. The 
qualitative examination upon which the diagnosis will depend 
should include the Weber, Rinne and Gardner-Brown tests 
(Chapter XXVIII). By repeating each test and then collat- 
ing and comparing all the results, the liability to error will 
be reduced to a minimum and a conclusion reached, which 
will be a safe guide in treatment. 

Chronic median otitis shows very little tendency to spon- 
taneous recovery; its duration depends almost wholly upon the 



Fig. iio. — Simple otitis 
media; chronic form. The 
drum-head is pushed in and 
very thin; the luminous tri- 
angle has receded from the 
periphery and the incudo- 
stapedial junction is visible 
on [account of the partial 
translucency of the mem- 
brane. 



SIMPLE OTITIS MEDIA 36 1 

therapeutic measures adopted. Its prognosis is far less favor- 
able than that of the acute type, but nevertheless it is often 
curable if the patient be able and willing to undergo a thorough 
course of treatment. This treatment comprises features 
growing out of the etiologic conditions, others that are con- 
stitutional and finally measures of a topical kind. As in the 
acute form, so here, every effort must be made to restore the 
health of the nose and throat and thus eliminate the causal 
factors of the otitis. If this restoration cannot be fully ac- 
complished, we may not hope for entire success with the ear, 
but must endeavor to confer upon our patient as much benefit 
as possible by such partial improvement as may be attainable. 

In this, like other chronic diseases, constitutional treatment 
assumes great importance. Local inflammations are usually 
self-limiting and when they fail to disappear the chronicity 
itself raises the suspicion that there is some systemic morbidity 
which nullifies the reparative efforts of the organism. Of 
the real nature of such morbidity we know little; it is re- 
ferred to as a diathesis and is thought to depend on disordered 
metabolism, hence if we can remove from the blood and the 
tissues deleterious substances, which the excretory organs have 
failed to eliminate and can supply in their place healthful nutri- 
ment, we may restore the vital functions to normal conditions 
and enable them to repair the damage wrought by disease. 
As our purpose is to promote changes in the blood and the 
tissues, it is obvious that what retards the process of elimina- 
tion and renewal must be avoided, hence coffee, tea, cocoa 
and alcohol are to be withdrawn from use while treatment of 
this kind is being employed. These theoretical considerations 
have the support of experience. It has been proved empirically 
that local inflammations which were intractable under topical 
treatment alone have speedily yielded when the local measures 
were reinforced by constitutional therapeutics, at first detergent 
and then tonic and roborant. 

In chronic affections of the middle ear the indications 
point, first, to laxatives, diuretics and warm baths, to promote 



362 NOSE, THROAT AND EAR 

the elimination of useless and injurious organic substances — 
all the remedies to be used with discretion, avoiding excess 
and adapting them to the individual requirements of each 
patient. The second stage of the treatment comprises a nu- 
tritious, unstimulating diet, moderate, regular, muscular exercise 
and, in some cases, the preparations of iron. The general 
tonic effect following a change of scenes and associations fre- 
quently proves very beneficial. 

If success attends the efforts directed to improvement of 
the general health, the results of local treatment will often be 
surprisingly good, both as to the res- 
toration of the tissues to their nor- 
mal state and as to the resumption of 
functional activity. For producing a 
direct effect upon the middle ear the 
procedures which I regard as most 
beneficial are inflation (Fig. in), aural 
massage and dilation of the Eustachian 
tube. 

meda'; chro^k'S. ° Ap! The introduction of air by the Politzer 
pearance of the drum-head bag and the Eustachian catheter al- 
ready described, may be rendered more 
efficient in chronic otitis by impregnating the air with medicinal 
vapors and sprays. Five or six drops of ethyl iodide or a like 
quantity of chloroform may be added to the atmospheric con- 
tent of a Politzer bag before an inflation and thus reach all 
parts of the interior in vaporized form. A two to five per 
cent, aqueous solution of ethylmorphine hydrochlorate (dionin) 
introduced by a pipette into the catheter is distributed in a 
similar way by the air blast from the Politzer bag. An oleagin- 
ous remedy is applied in nebulized form by putting into an 
atomizer a solution of camphor and menthol (two per cent, aa) 
in liquid petrolatum, throwing its spray into the catheter and 
then distributing it with the air blast. All these remedies 
are of approved value, the one best suited to each case de- 




SIMPLE OTITIS MEDIA 363 

pending upon pathological details: sometimes they prove very 
efficient when used interchangeably. 

Massage of the membrana tympani by the successive con- 
densation and rarefaction of the air upon its outer surface is 
effected with the Siegle otoscope and Delstanche masseur 
(Chapter III), their careful use often proving very beneficial. 
Another instrument applied to the exterior of the drum-head 
is the Lucae probe. This has a cup-shaped end which is placed 
directly over the short process of the malleus, or the stapedio- 
incudal junction, and is then alternately compressed and re- 
tracted in a gentle manner with the purpose of imparting 
vibration to the malleus and other ossicles, which have become 
more or less agglutinated by inflammatory products. 

The dilation of the Eustachian tube by bougies or by electrol- 
ysis, mentioned in connection with obstruction (Chapter XXX), 
is at times required in chronic otitis, though the tube is often 
greatly improved as a result of etiologic and constitutional 
treatment such as has been detailed. 



CHAPTER XXXII 



PURULENT OTITIS MEDIA: ACUTE AND CHRONIC 




This type of otitis is characterized by the presence of pus 
which either perforates the membrane or the osseous walls of the 
tympanum spontaneously, or is found within its cavity when 
there is incision of the drum-head. Its etiology is virtually the 
same as that of the simple form, with the addition of the 
circumstances and incidents, which intensify or prolong the 
inflammation to such an extent that 
it becomes suppurative, and among 
these the commonest aggravation 
is that caused by the neglect of treat- 
ment. The affection is generally 
unilateral and its symptoms have the 
same order of development as is ob- 
served in unilateral, simple otitis, 
but they are said to be more severe 
through all the stages and even at 
the onset. I think this often reit- 
erated statement is a less accurate 
expression of the facts than is given 

the drum-head was filled with by saying that otitis of mild type 

pus, which was evacuated by ., j , 

incision. ma y run lts course and terminate 

by resolution, even without treat- 
ment, such a case being classified as simple and acute, while 
otitis of severe type will, unless modified by treatment, ad- 
vance to suppuration and be called purulent. In other words, 
the disease is not severe because it is purulent, but purulent 
because it is severe. Fig. 112 shows the drum-head distended 
with pus. 
This affection is very common in infancy and childhood 
364 



Fig. 112. — -Purulent otitis 
media. The distended part of 



PURULENT OTITIS MEDIA 365 

where the rapidity of tissue change leads to inflammatory proc- 
esses from causes which do not produce them in the adult. 
It accompanies the infectious fevers so often that its presence, 
at some stage in their course, may be anticipated and the fre- 
quency of this connection is proved by the statistical observa- 
tion that pus is found in the middle ear at all postmortem ex- 
aminations following scarlet fever, measles and smallpox, and 
in a large proportion of those following diphtheria. This and 
other facts lead to the conclusion that it is a rare thing to find 
an individual, who has not at some time in his life had pus in 
the tympanic cavity. This part of the organism is evidently 
very susceptible to the morbid influences which cause sup- 
puration, a fact which influences both our prognosis and our 
tre atment, but side by side with this fact is another of equal 
significance; this portion of the ear is endowed with great re- 
cuperative power; its liability to disease has an offset in its 
capability of recovering from the effects of morbid influences. 
This is incontestibly shown by the aural state of recruits for 
our army and navy and by the occupational examinations now 
so much in vogue. In a large majority of the adults subjected 
to tests conditions are normal, or nearly so, in spite of the vicis- 
situdes through which they have passed in earlier years. It 
thus appears that the middle ear is a peculiarly important 
field from the professional point of view; a field capable of much 
fuller cultivation than it has yet received, for it needs an un- 
usual amount of therapeutic care and it will respond favorably 
to such care in a degree equally unusual. 

The microbes found in the discharges, whether they are etio- 
logic or only coincident, are not restricted to a particular species. 
Streptococci are commonly present when the otorrhceais associ- 
ated with measles or scarlet fever, the pneumococcus and 
bacillus tuberculosis have been observed in diphtheritic cases 
and in some of rhinologic origin, while nearly all constitutional 
diseases intercurrent with the otitis are at times represented in 
the secretions by their own characteristic germs. The bacterio- 
logical findings do not, at present, throw much light upon treat- 



366 NOSE, THROAT AND EAR 

ment, except to emphasize the importance of careful and 
continuous asepsis. 

Impairment of hearing is a constant symptom, but there is 
much variation in its degree and also in its persistence. It may- 
continue for weeks or even months and then disappear leaving 
the function in a normal, or nearly normal condition. The de- 
fect is in the tones of low pitch and unless there is coexistent 
disease of the internal ear, the tones of high pitch are but little 
affected. The other factors of the symptom-complex already 
given are modified chiefly by the phenomena of intercurrent 
constitutional maladies, or by the mechanical effects of purulent 
accumulations. Scarlet fever, which manifests a marked tend- 
ency to injure the ear and all contiguous organs, may cause 
facial paralysis, or may start suppuration in the lymphatic glands 
of the neck developing pari passu with the purulent otitis media. 
Imprisoned pus will cause the drum-head to bulge into the ex- 
ternal auditory meatus and will give to the tinnitus present a 
peculiar pulsating quality, the noise assuming rhythmical 
characteristics in unison with the beating of the heart. This de- 
velopment is accompanied by throbbing pain, radiating from 
the tympanum and sometimes associated with tenderness over 
the mastoid, even prior to the involvement of the mastoid cells. 

Between acute, purulent otitis media and the chronic type 
of the disease no hard and fast line can be drawn. One form 
merges into the other by gradations which sometimes put the 
emphasis upon one development, sometimes upon another. 
Aside from the fact of chronicity itself, the most characteristic 
differential sign of the long-established process is the outflow of 
pus through an aperture in the membrana tympani. The for- 
mation of such an aperture appears to be a mechanical necessity, 
in view of the accumulation of pus within the tympanic cavity ; 
if such accumulation extends beyond a very brief period, hence 
the "running ear" is associated with a continuing otitis. Un- 
doubtedly, this association is nearly always justified by the facts, 
but even here we may find an anomaly. It is possible that a small 
quantity of pus might exude from a pyogenic area of very limited 



PURULENT OTITIS MEDIA 367 

extent and be carried away by the Eustachian tube, so that the 
suppuration might continue some time without producing dis- 
tention of the membrane or giving any other notable sign of 
its existence. 1 In such a case there would be chronic purulent 
otitis media without perforation of the drum-head. Such a 
rare phenomenon is suggested as a possibility of morbid action 
in this region, where we must always be prepared to encounter 
the exceptional. It is now universally recognized that the aural 
affection is usually dependent upon nasal morbidity and that 
when the nose is cured, spontaneous recovery may occur in the 
ear, hence a thorough rhinological examination should always be 
made and if abnormal conditions are found, every effort should 
be made to correct them before applying active treatment to 
the ear, provided the aural and constitutional condition allows 
an interval of delay during which local treatment of the ear is 
restricted to palliative measures. 

In acute cases, the first step in topical treatment is often 
myringotomy. This is indicated when the tympanum is 
filled by a liquid which, on account of obstruction in the 
Eustachian tube, has no avenue of escape. Through the 
speculum the membrana tympani appears congested and 
bulging outward, while the coincident symptoms are fever, 
tinnitus, partial surdity and throbbing pain. When these 
conditions are present, the external auditory meatus is to be 
cleansed with a solution of sodium bicarbonate, two drams 
to a pint of water, and then wiped out with a solution of 
carbolic acid, ten per cent, in glycerine, applied by a cotton- 
tipped probe. This deadens the pain in some degree and, as 
the operation is very quickly done, I am in the habit of per- 
forming it without any other anaesthetic, but if the patient 
is nervous and very apprehensive, he should inhale enough 
ethyl chloride to induce a very brief anaesthesia. The opera- 

1 In a case like that postulated, if the concealed pus should ultimately enter the 
antrum and set up mastoiditis, the process would explain disease of the cells, 
which otherwise would be considered a primary affection, something whose 
occurrence is not free from doubt. 



368 NOSE, THROAT AND EAR 

tion is done with the myringotome, a slender bistoury, and the 
incision made with it through the membrane is crescentic in 
shape; it begins at a point just below the incudo-stapedial 
articulation and extends along the posterior side of the mem- 
brane downward and forward for a distance of about six milli- 
meters. Through this opening the incarcerated fluid escapes 
into the meatus, whence it is carefully removed and a wick of 
gauze inserted for drainage ; after this the ear is covered with a 
sterile dressing. Inflation with the Politzer air bag should 
be practised daily after the operation and, if the discharge is 
profuse, a hot solution of boric acid, 3 j to Oj, should be used 
for irrigation. Generally there is rapid decline in the fever 
and pain after the pus is liberated, but in some persons there 
are exacerbations of pain at intervals. In these cases a hot- 
water bag applied over the auricle affords relief. The tendency 
of wounds of the membrana tympani to heal very rapidly may 
bring about a closure of the outlet while suppuration still 
continues. In this case the myringotomy must be repeated and 
an orifice kept open until the otorrhcea ceases through the 
cure of the inflammation, when the aperture is allowed to 
close. Afterward the inflations are to be continued upon 
alternate days, until tinnitus disappears and the hearing re- 
gains its normal acuteness. 

Long-continued inflammation very often stimulates cellular 
production, but the creative energy is misdirected and the 
resultant growths are of morbid character and tend to displace 
and destroy the normal tissues which surround them. The 
histologic elements of such growths are sometimes unnatural 
and foreign to the human body, but much oftener they are cells 
which would be normal in their proper environment, but become 
injurious by growing in improper places. 1 Chronic purulent 

1 The ancient physicians who were fond of expressing ideas in proverbial 
form, especially in rhymes which helped to fix them in the memory, incorporated 
this thought in Latin verse: 

"Res natura bona?, 
Quum male positae, 
Sint saepe pessima?." 



PURULENT OTITIS MEDIA 369 

otitis media is frequently complicated by cholesteatomata, which 
are misplaced and degenerated accumulations of cellular 
elements naturally belonging to the epidermis. The patho- 
genesis of these masses usually begins by an extension of the 
skin from the external meatus into the tympanic cavity, where 
the epithelium gradually loses the qualities characteristic of a 
seromucoid membrane and takes on those of the cuticle. Under 
the hyperplastic stimulation of the chronic otitis, there is rapid 
proliferation and desquamation of epithelial cells, which are 
carried away in the purulent discharge and may readily be de- 
tected by a lens of moderate magnifying power. The presence 
of such cells is of much diagnostic value provided the precau- 
tion has been taken to thoroughly cleanse the external auditory 
canal before taking a specimen for examination. Otherwise, 
the middle-ear discharge may be contaminated by substances 
originating in the meatus, prompting a wrong judgment. So 
long as the proliferation of these cells is balanced by their dis- 
charge with the suppurative outflow, they give rise to no special 
symptoms, but when such a balance is disturbed, as it is likely 
to be, their accumulation soon alters the intratympanic condi- 
tion. A slight obstruction causes the retention of a few cells; 
these form the basis for an aggregation which, as it increases, 
steadily adds to the obstruction so that the cellular mass grows 
at a rate which constantly tends to acceleration. This enlarge- 
ment inaugurates the second stage which continues until the 
available space is all occupied, except a passageway of variable 
size through which there is still drainage of pus, though 
often in lessened quantity. The cholesteatoma now shows the 
effects of the pressure exerted by surrounding structures and it 
invades any cavity where it has a chance for expansion. In 
this way the attic is occupied to its fullest capacity and the 
growing mass pushes on through the adjoining aditus into the 
antrum unless, prior to this invasion, its expansion has been 
arrested. While this process goes on under continuous pres- 
sure, the mass becomes much denser and passes through changes 
which simulate those of neoplasms, though it does not reach a 



37° NOSE, THROAT AND EAR 

true organization of structure. The epithelial elements, greatly 
compressed, tend to an arrangement in concentric layers, en- 
veloping a core of caseous matter made up of inspissated pus 
and of cells undergoing fatty degeneration, and the external 
surface may be covered by a smooth, thin capsule. The con- 
tinued growth of this morbid mass, coupled with the lack of room 
for its accommodation, ushers in the destructive stage, during 
which the contiguous soft parts are removed by atrophy or by 
ulceration and the compressed bony walls, deprived of their 
blood supply, undergo gradual absorption. As a result, the 
cholesteatoma may penetrate the tegmen tympanicum and cause 
intracranial infection, or a fatal haemorrhage may be caused by 
erosion of the walls of the lateral sinus or of the internal carotid 
artery. 

The symptoms, which are more or less intermittent, are pain 
due to pressure and a sense of weight and fulness in the tym- 
panum together with a variable degree of surdity. The morbid 
mass is itself insensitive, as it is devoid of nerves. The im- 
pairment of hearing bears little relation to the gravity of the 
disease and may continue slight up to the onset of fatal invasion 
of the brain. The extent to which audition is affected depends 
less upon the size of the morbid growth than upon the integrity 
and mobility of the ossicular chain and normality of the 
inner wall of the tympanum, through which in many cases vibra- 
tions continue to be transmitted, although the atrium is nearly 
filled by degenerating cells. The diagnosis rests upon careful 
observation of the morbid process and on finding cutaneous 
epithelium in the purulent discharge. When it is habitually 
present, there can be little doubt of the presence of a cholestea- 
toma, and when it is suspected, search for it should be patient 
and thorough. 

Treatment has as its object the eradication of the growth 
and the prevention of recurrence. When the mass is of moder- 
ate size, within view through the speculum, and not incapsu- 
lated, it is often practicable to break it up and wash it away 
with a warm solution of mercury bichloride, one part in three 



PURULENT OTITIS MEDIA 



371 



thousand (1 : 3000) . The ordinary aural syringe proves effi- 
cient for this purpose, when the mass is in the atrium, but if 
it fills the attic, as it frequently does, it may be necessary to 
employ a specially adapted instrument, such as that of Hewitt 
(Fig. 113). When unusual density and hardness prevents dis- 
integration, softening can usually be effected by instilling the 
stock solution of hydrogen peroxide, drop by drop, until the 
frothy appearance of the surface of the impaction shows that 
the chemical reaction is taking place, when the syringing can be 




Fig. 113. — Hewitt's apparatus for dislodging cholesteatomata from the 
middle ear. 



resumed with better prospect of success. In exceptional cases, 
it may be necessary to employ a small ring- or spoon-shaped 
curette to break up a mass that is peculiarly hard and dry, 
so that its fragments may come away with the water jet. This 
will be facilitated by applying with a pipette a few drops of the 
usual (1 : 1000) solution of epinephrin chloride which by blanch- 
ing and contracting the lining membrane of the tympanum will 
retract it from contact with the morbid mass, thus rendering 
the latter movable. 

When cholesteatomata can be dislodged in the way described 
and their fragments removed through the external auditory 
meatus, this is the method of preference, but sometimes they 



372 NOSE, THROAT AND EAR 

are too large, cases having been reported where the incapsu- 
lated mass reached the size of a pigeon's egg. In such instances 
they have, by effecting destruction of the osseous partitions, 
converted the tympanum, antrum and mastoid cells into a single 
cavity, not only rendering an operation from the outside neces- 
sary, but in a sense paving the way for its performance. 

Polypi constitute another complication of chronic purulent 
otitis media (Fig. 115). The structure of these growths has 
already been discussed in Chapter V and here it is only neces- 
sary to add that when occurring in the middle ear they are 
the result of the exuberant granulations induced by chronic 
purulent inflammation. When they have a distinct pedicle, 
as they commonly do, the best method of treatment is extirpa- 
tion with the cold wire snare (Fig. 114). The pain caused by 




Fig. 114.— Blake's cold wire snare for removal of growths from the external 
auditory meatus and the tympanum. 

this operation is slight, but it is well to paint the polyp with a 
four per cent, solution of cocaine and one of epinephrin chloride 
(1 : 1000) as the former will prevent any suffering and the latter 
will forestall any probability of haemorrhage. After the appli- 
cation of these solutions, the snare loop of fine, brass wire is ad- 
justed over the bulb of the growth and brought as close as possi- 
ble to the base of the pedicle. It is then slowly withdrawn into 
the shaft of the instrument and the polyp strangulated and 
excised. When the pedicle is very short, or the growth is sessile, 
cutting forceps (Fig. 116) may with advantage be substituted for 
the wire snare. The raw surface left by either instrument is to 
be dusted with boric-acid powder which is often the only sub- 
sequent treatment required. If the healing process is tardy, the 
denuded spot should be touched with a bead of fused chromic 
acid, any superfluous action of the caustic being checked by 
powdered sodium bicarbonate. 




Fig. 115. — Polypus protruding through perforation in Shrapnell's membrane 
and chalk deposits in drumhead caused by chronic, purulent otitis media. 



{Facing page 372.) 



PURULENT OTITIS MEDIA 373 

To prevent the recurrence of cholesteomata and polypoid 
growths, we must secure efficient cleansing of the region affected 
by the otorrhcea and, as far as may be possible, render it 
aseptic, while treatment is continued for the cure of the otitis. 
Signs that the growths are returning indicate the use of fused 
chromic acid at the point where the marks of recurrence appear, 
and this will generally prove an efficient check without causing 
any severe reaction. 

The therapeutic measures detailed above may be expected 
to effect a cure in uncomplicated cases and also in many at- 
tended by complications, provided the diseased action is re- 




Fig. 116. — Hartmann's cutting forceps. They are adapted for removing 
polypoid growths, which are sessile, or have very short pedicles. 

stricted to the membranes lining the tympanum, or to out- 
growths and proliferations of those membranes. We may hope 
to restore the membranes to a normal state and thus put an 
end to the otorrhoea and the other consequences of their mor- 
bidity, but if the ossicles have become necrotic, the damage is 
probably irreparable and their carious condition will keep up 
the obstruction and suppuration as long as they remain in place. 
Under such a condition it may be best to resort to ossiculectomy, 
the sacrifice of the bones proving but a small loss, because on 
account of necrosis they have already lost their functional value 
as a part of the conducting mechanism of the ear. 

In ossiculectomy the instrumental work must all be done 



374 NOSE, THROAT AND EAR 

through the space encircled by the tympanic ring, hence the 
membrane must be freely incised to give room for the operation. 
When there already exists a large perforation, the best plan is 
to extend its area as much as necessary by cutting toward the 
surrounding ring, the exact method being determined by the 
locality and the size of the existing orifice. When this is too 
small to be available, a satisfactory opening can be made by a 
crescentic incision beginning at the posterior fold of the drum- 
head and extending downward and forward to the anterior 
fold. By this aperture the tympanic cavity is exposed to view 
and room given for the subsequent procedures. This para- 
centesis and the following operation may be performed under 
general anaesthesia, but the local method is usually preferable. 
For this purpose use is made of a hypodermic syringe with a 
long needle, and into its barrel is put the following solution, 
all of which is to be slowly injected. 

1$. Cocaine hydrochlorate gr.f 

Epinephrin chloride, solution (i : iooo) V([ 2 

Normal salt solution q.s. ad. TH. 15 M. 

The needle makes a puncture in the cutaneous lining of the 
upper wall of the external auditory meatus at the junction of 
the cartilaginous and osseous portions, and the injection is made 
at this point (Fig. 117). Immediately afterward a plug of 
gauze or cotton, saturated with a solution of the same strength, 
is applied to the surface of the membrana tympani arid hastens 
the anaesthetic effect by reinforcing the injection. The de- 
sensitization produced extends over the whole field of the pro- 
jected operation and becomes complete in from eight to ten 
minutes. 

On account of the shape and structure of the ossicles and the 
contracted space in which the operation must be performed, 
ossiculectomy requires an assortment of specially adapted in- 
struments and those which I consider best suited to the purpose 
are shown in Fig. 118. 

Naturally the malleus is the first ossicle to be ablated. An 
angle-bladed knife (Fig. 118D) is employed to cut the tendon 



PURULENT OTITIS MEDIA 375 

of the tensor tympani muscle which is divided between its 
attachment to the malleus and the internal (labyrinthine) wall 
of the tympanum. To make sure that the tendon has been sev- 
ered, it is well to pass the point of a bent, slender probe beyond 
the malleus and to move it along the surface of the ossicle 
where, if the tendon has not been divided, it will be encountered 
by the instrument. The angle blade of the knife is introduced 
again to free the malleus from connective-tissue adhesions and to 
separate it from the incus at the point of articulation. The 




Fig. 117. — Position of needle to inject anaesthetic into wall of external auditory 
meatus. 

ossicle is then grasped with forceps (Fig. 118C) and a movement 
of partial rotation, to and fro, used to dislodge it. When 
found to be free, it is thrust backward and downward from the 
attic into the subjacent space and then withdrawn through 
the incised membrane and the external meatus. 

Ablation of the incus is affected by severing it from the stapes 
at the incudo-stapedial articulation with the angle-bladed knife, 
and then dislodging it with the incus hook (Fig. 118F), a raa- 
nceuver at times rendered less easy by the loss of a part of the 
ossicle by necrosis — an occasional result of prolonged suppura- 



376 



NOSE, THROAT AND EAR 



tion. The dislodged incus is extracted by the same route as 
the malleus and, in all the measures detailed, particular caution 




Fig. 118. — Instruments used in operating on the ossicles. A, Denche's 
straight tympanum perforator; B, D, E, Sexton's ossicle knives; F, incus hook; 
C, Sexton's ear forceps; G, Randall's mastoid curette, double ended; H, mastoid 
mallet, lead filled head; /, Alexander's mastoid chisel. 



is observed not to injure the stapes nor to loosen its foot plate 
from its normal implantation at the oval window, for the per- 
manent closure of this orifice is essential to the protection of the 



PURULENT OTITIS MEDIA 377 

internal ear and also the intracranial structures. It has been 
found that to attain the objects aimed at in the operation of 
ossiculectomy, the attic must be resected by the excision of its 
lateral (outer) wall. This may be done with a sharp-edged 
curette (Fig. 118G) or with mallet and chisel; in using the latter 
implements it is best to have the blows struck by an assistant, as 
the operator is likely to need both hands to properly direct and 
safeguard the cutting edge. To protect the facial nerve, the' 
epitympanic space may be filled with cotton as a barrier be- 
tween the chisel and the facial canal. At the close of the opera- 
tion an incision at the site of the injection given to induce 
anaesthesia will obviate any danger from tumefaction or the 
possible formation of pus. The subsequent treatment com- 
prises cleansing the wound with alkaline, antiseptic solutions and 
lightly packing the external auditory meatus with sterile, iodo- 
form gauze, over which is placed a light, sterile dressing, which 
covers the auricle and is kept in place by a bandage. Exuber- 
ant granulations must be checked if they appear and all other 
details of management during convalescence must be regulated 
by the surgical principles applying to postoperative treatment. 
The various diseases, which may develop as consequences of 
acute inflammation of the middle ear, or the chronic and sup- 
purative manifestations of its morbid condition, are induced 
almost without exception by an intense and extended implica- 
tion of the pneumatic cells which converge into the antrum, 
hence mastoid involvement constitutes a very grave consequence 
of otitis media and is always borne in mind as, at least, a possi- 
ble result. When, despite the use of appropriate medicines 
and despite the operations just considered, the purulent otitis 
media persists, the suspicion that the mastoid cells are affected 
naturally arises and it is much strengthened by the superven- 
tion of any of the symptoms or physical signs, enumerated in 
Chapter XXXIII. As surgical operations upon the mastoid are 
a serious matter, not free from danger, conservatism dictates a 
reasonable delay, seven or eight weeks, during which persistent 
efforts are made to effect a cure by the use of both local and 



378 NOSE, THROAT AND EAR 

general measures, medicinal and hygienic, while extirpation of 
the mastoid cells is held in reserve. This course is advised 
when the phenomena of the otitis indicate no urgency for a 
change in policy. The occurrence of certain symptoms is a 
warning to employ surgical measures at once. One of these 
symptoms is facial paralysis whose advent is of grave import. 
The loss of hearing for tones of high pitch accompanied by 
disturbances of equilibrium and by nausea or vomiting indicates 
that the labyrinth is being subjected to pressure and that 
mastoidotomy should be performed without delay to relieve 
that pressure. Either at the call of such emergencies or because 
a patient, conservative treatment has proved unsuccessful, 
surgery of the mastoid is our final resort. This must always 
have as a precedent condition, a free opening through the mem- 
brana tympani, which indeed has nearly always been made 
during the former treatment, but if it has not, or the aperture 
has closed, the matter must invariably receive attention before 
resorting to external incision. The cessation of the discharge 
in suppurative otitis media may be accompanied by a temporary 
increase in the deafness on account of the drying and stiffening 
of the drum-head. The patient should be warned of this possi- 
bility, or blame may be cast upon the treatment pursued. In- 
flation and massage should be used until the hearing returns. 
Sometimes a sequel of the disease is a permanent perforation of 
the drum-head (Fig. 119). This deformity seldom gives pain or 
causes tinnitus, but it impairs the hearing for tones of low pitch 
and also subjects the tympanum to injury by the entrance of 
deleterious substances from the external meatus. Occasionally 
deposits of chalk take place in the cicatrices following perfo- 
rations, as shown in Fig. 120. Some of the orifices in the 
membrane may be surrounded by granulation and closed by 
a cicatrix, if their edges are lightly cauterized with silver 
nitrate or trichloracetic acid. If they resist treatment, the 
patient should protect the middle ear by a light packing of 
cotton in the meatus and should revisit the surgeon at inter- 
vals of two or three months for the removal of the crusts which 



PURULENT OTITIS MEDIA 379 

are apt to form upon the margin of the perforation. Efforts 
have been made to substitute an artificial drum-head for one 
which has been much damaged. The device most used is a 
circular disk of thin rubber to which is attached a wire extend- 
ing to the conchal end of the meatus. This instrument often 
gives some help to the hearing, but it is by no means free from 





Fig. 119. — Permanent perforation Fig. 120. — Permanent orifice and 

through Shrapnell's membrane: an chalk deposits in drum-head caused 

instance of residual, purulent otitis by chronic, purulent otitis media. 
media. 

danger and nearly, or quite, as much benefit accrues from press- 
ing a small ball of cotton against" the perforation, a method 
introduced by Yearsley in 1842. This pledget of cotton, if 
kept clean by frequent renewals and carefully inserted and re- 
moved, is unobjectionable and will probably accomplish nearly 
all in the way of improvement that can be attained. 



CHAPTER XXXIII 
MASTOIDITIS 

The mastoid portion of the temporal bone called, for brevity, 
simply the mastoid lies directly behind the auricle and is con- 
sidered a part of the middle ear, or at least associated with it 
in a functional as well as an anatomical way. The cavities 
existing within it all normally contain air and they are believed 
to play a physiological part in audition, but what this is has not 
been determined with certainty. Their role in the pathology 
of the middle ear is well understood and is most important. 
The mastoid, like other structures in this region, exhibits a great 
deal of anatomical variation, a fact which requires surgical pro- 
cedures to be conducted with special caution. At birth this 
bone is simply an envelope inclosing a single air-filled cell, 
lined with mucous membrane, the antrum; all the rest is the 
product of development which continues through infancy and 
adolescence, and may not be complete until the age of full 
maturity. The descriptions hereafter given apply to the con- 
ditions usually found in persons of twenty years or more. 

The upper border of the mastoid is in contact with the dura 
mater and forms part of the cranial floor; the posterior border 
articulates with the occipital bone and is penetrated by several 
foramina, the largest of which gives passage to the occipital 
artery and to a vein terminating in the lateral venous sinus; the 
lower border slopes to a conical projection, called the mastoid 
tip, which gives attachment to the sternomastoid muscle and 
is perforated from above downward by the stylomastoid fora- 
men of the Fallopian canal, affording passage to the facial nerve 
which here emerges from the skull and proceeds forward to its 
distribution in the muscles of the face; the anterior border forms 
the osseous section of the external auditory meatus and parallel 
3 8o 



MASTOIDITIS 381 

with this margin in the substance of the bone is the Fallopian 
canal, referred to above. Upon the intracranial surface is a 
well-marked groove occupied by the sigmoid sinus. 

The varied and often anomalous development of the mastoid 
has led anatomists to distinguish three structural types: the 
eburnated, with hard, dense bone and very few cavities; the 
diploic, characterized by loose, porous tissue like that found be- 
tween the two cranial tables; and the pneumatic, where there 
are many cellular spaces filled with air and the osseous tissue is 
somewhat scanty and appears to serve chiefly in forming the 
partitions between these pneumatic cavities. These variations 
exert a great influence upon pathological processes and necessa- 
rily modify therapeutic measures. 

The mastoid cells are spherical or spheroid in shape, are lined 
with a nonciliated mucosa and histologically resemble the nasal 
sinuses (Chapter IX). Small tubules furnish communication 
with the. antrum so that if a liquid be injected into one of the 
cells, it will gradually find its way into the others. The largest 
cavity within the mastoid and the only one that is never want- 
ing is the antrum, located near the tympanum and opening into 
the attic. This cell lies at a depth from the exterior surface of 
the bone which frequently measures half an inch and sometimes 
even more, while the osseous partition separating it from the 
dura mater is often extremely thin. 

Mastoiditis, or inflammation of the mastoid cells, is almost 
always secondary to suppurative otitis media, pus from the 
tympanum entering the antrum through the aditus and in- 
augurating a similar morbid process throughout the group of 
cells. It is said that the disease is sometimes primary, but this 
must be very rare and in such a case the isolation of the infec- 
tion within the mastoid would be very brief, for the cells have 
no outlet except the aditus and their morbid secretions would 
speedily invade the tympanum and produce there an inflamma- 
tion of identical type; so whether the movement be from mastoid 
to tympanum, or the reverse, the consequence is that in a very 
short time, both become involved and are conjoined as factors 



382 NOSE, THROAT AND EAR 

in our therapeutic problem. For this reason, primary mastoid- 
itis appears to have little beyond academic interest. The dis- 
ease, as we habitually see it, arises during purulent otitis media, 
by the direct passage of pathogenic liquids into the antrum and 
other cells, probably also in some few instances, by infection 
through the vascular circulation. 

The symptoms which accompany the invasion of the mastoid 
are pain, tenderness, muscular rigidity and pyrexia, often asso- 
ciated with alterations in the suppurative process already 
established in the tympanum. The pain is felt directly behind 
the auricle and is described as a deep-seated, severe, constant 
aching; it grows worse at night, bringing on insomnia with its 
depressing effects. Tenderness is present over the entire mas- 
toid area and is elicited by deep pressure, particularly upon 
the tip of the bone. The tenderness is often of such intensity 
that the patient flinches when the hand approaches his ear. 
Where this symptom is so marked, its diagnostic value is great, 
for hardly anything except mastoiditis would produce it. 
Muscular rigidity is present when the lower part of the bone is 
much inflamed. There is often a large cell within the tip and 
its involvement affects the sternomastoid muscle, here attached, 
to such a degree that rotation of the head is difficult and pain- 
ful. In uncomplicated cases, the pyrexia is not severe; the 
acceleration of the pulse is not more than twenty or thirty beats 
and the rise in temperature does not exceed two or three degrees, 
while thirst, anorexia and other febrile symptoms are slight, or 
even absent. Considering the serious nature of the local dis- 
ease, the constitutional disturbance is surprisingly moderate. 
We see here a vivid contrast between this complaint and tonsil- 
litis in which the systemic manifestations exhibit a severity 
very disproportionate to the intensity of the faucial disease. 
Extension of the morbid process from the tympanum to the 
mastoid affects the existing suppuration in ways that may in- 
dicate the diagnosis. When there suddenly occurs cessation, 
or notable decrease, in an otorrhcea previously abundant, we 
may suspect an involvement of the mastoid cells. If the 



MASTOIDITIS 383 

pus has been washed out of the tympanum and the thoroughly 
cleansed cavity fills up again very quickly, the conclusion is 
obvious that the purulent secretion comes from within the mas- 
toid, because there has not been time enough for its production 
by the intratympanic membrane. It may be added that 
discharges from the mastoid cells are apt to be discolored by 
blood and putrefactive matters and to give out a foul odor, even 
in early stages of the inflammation. 

As the only natural outlet of the antrum and its conjoined 
cells is through the aditus and tympanic vault, if by any means 
they be occluded, the incarcerated pus must make a way of es- 
cape. Sometimes it finds egress through the cortex of the bone 
whose substance has yielded to destructive ulceration. In 
such a case, the pus distends the overlying integument, form- 
ing a warm, fluctuating tumor which increases in size until the 
limit of cutaneous resistance is reached and there is spontaneous 
rupture at the weakest point. The passage of the pus through 
the cortex is accompanied by amelioration of the pain and other 
symptoms. This favorable turn in the course of mastoiditis 
occurs in those instances where the cortical layer of bone is thin, 
or has undergone some softening. When its firm texture re- 
sists the pressure of the imprisoned fluid, the purulent mass 
breaks through the thinner wall upon the intracranial side of 
the bone, causing extradural abscess, sinus thrombosis, menin- 
gitis, or cerebral or cerebellar abscess and sometimes general 
sepsis. The occurrence of such a rupture is often signalized by 
rapid rise in temperature, by dizziness, by nausea or vomiting 
and by the onset of delirium, or other psychic symptoms. 

In mastoiditis the prognosis must always be guarded, because 
the morbid conditions are, to a great extent, hidden from view 
and can be judged by inference only and because the proximity 
of the brain and the weakness of the structural barriers, which 
protect it from invasion, constitute a feature of grave danger. 
Very much depends upon judicious treatment and especially 
upon the discretion used in determining just when surgical in- 
terference is necessary and just what form that interference 



^84 NOSE, THROAT AXD EAR 

shall assume. Nothing can be ordinarily foretold as to the du- 
ration of the disease; the number of indeterminate factors is so 
large that they render unwise any attempt at prediction. 

The inaccessibility of the mastoid cells is a cogent argument 
for surgical measures. The fact that their natural entrance 
affords hardly any chance for either examination or treatment, 
is surely a very good reason for making an artificial entrance 
which will enable us both to see and to act. This, in my judg- 
ment, is truly conservative surgery, and yet there is a period at 
the very beginning of mastoid inflammation, when it is possible 
to bring about resolution, or termination of a suppuration that is 
only incipient. In using nonsurgical measures for this pur- 
pose, the thing which demands the best judgment and the 
closest discrimination is to determine just when it is our duty 
to lay aside other things and take up the knife. 1 

When the decision is made to employ the antipyretic method 
of treatment, all its resources must be brought to bear'at once, 
for at best it offers only a chance of success and its tardy or par- 
tial use may serve only to convert this chance into the certainty 
of failure. Accordingly, the patient must be kept in bed, given 
a warm bath and a brisk saline cathartic, followed by use of a 
milk diet and free drinking of pure water. The best attainable 
drainage must be given the tympanic cavity and, if required to 
accomplish this, the incision through the membrane previously 
made must be enlarged; in addition the meatus and tympanum 
are to be irrigated with a saturated solution of boric acid of 
moderate warmth, not only to wash away the accumulated pus, 
but to encourage its flow from the antrum and aditus.^ The 
dizziness produced by warm injections, when the patient is 

1 When antecedent medicinal treatment appears to be for the patient's good, 
its adoption is favored by another reason. At the present time prosecutions for 
damages supply the only pabulum of a large number of lawyers who accordingly 
are persistent in fomenting suits for malpractice. If a mastoid operation 
results unfavorably, the surgeon is liable to be held responsible, unless he can 
prove that it was not only well performed, but was absolutely necessary. The 
fact that medicinal treatment was faithfully tried, before the resort to surgery, 
is a strong point in the defence. Upon the ground of self-protection, it may 
prove to have been a most judicious precaution. 



MASTOIDITIS 385 

standing or sitting, is very much lessened in the recumbent 
posture and may be altogether absent. To check the tendency 
to suppuration and gain time for the effects of the constitutional 
treatment, we rely on the topical use of cold, applied either 
by an ice bag, or by Leiter's coil through which ice-water 
passes slowly, producing on the surface of the tube a tempera- 
ture of about 36 F. 1 In nearly every case these antipyretic 
measures will cause an amelioration of the symptoms, but 
this may be misleading, as it occurs when the local disease is 
arrested and also when it is not; in the latter case the mitiga- 
tion proving only temporary. Mindful of this important fact, 
the ice bag or coil should be removed at the end of thirty-six 
hours and the irrigations suspended, careful note being taken of 
favorable changes in pain and tenderness. If after the lapse of 
two or three hours, a further improvement be observed, we con- 
clude that resolution is taking place and resume the treatment, 
but if deep pressure shows a return of the hyperassthesia and the 
patient complains of more pain, there is but one interpretation 
for these symptoms: the mastoiditis has been insidiously ad- 
vancing all the time and our apparent gains have been due, not 
to control of the local morbidity, but simply to constitutional 
sedation. The condition now confronting us is a signal to stop, 
a signal as imperative as the red lantern waved before a moving 
train, and it signifies — drop the antipyretic treatment and 
operate. 

In view of the fact that such a course may become mandator) 7 
in any case, it is the part of wisdom to have the preparations 
for the operation made in advance, both as to the assistants 
needed and the instruments required. The exhibit in Fig. 121 
shows everything that is at all likely to be needed in the opera- 
tion done with the technique which I consider the best, some 
of the instruments being used only to meet exceptional require- 
ments. The surgeon encounters no difficulty in choosing an 

1 Many authors advise the local abstraction of from one to three ounces of 
blood by the application of leeches behind the auricle; some preferring the 
living worm and others the mechanical substitute, or artificial leech. 



386 



XOSE, THROAT AND EAR 




Fig. 121. — Instruments for simple mastoid operation. (Schwartze.) A, All- 
port's mastoid retractor; B, periosteal elevator; C, Randall's gouge; Z), Hart- 
mann's mastoid rongeur; E, McKernon's mastoid curettes; F. F., Volkman's 
retractors 



MASTOIDITIS 387 

operation, because that devised by Schwartze has won an ap- 
proval that is almost unanimous, as following the golden mean 
between what is incomplete and ineffective upon one hand, and 
what is too radical and destructive upon the other. It was 
formerly the practice to evacuate purulent accumulations by 
making a small perforation into the antrum. This palliated 
the symptoms, for the time being, by lessening pressure and 
withdrawing some of the pus, but it left the pyogenic lining of 
all the cells in a morbid state and hence was followed by long- 
continued suppuration, frequently leading to necrosis and to 
intracranial infection. Schwartze pointed out the necessity of 
fulfilling in this disease the requirements emphasized by the 
laws of asepsis which insist upon the removal of all morbid 
tissue as an indispensable antecedent to repair and recovery. 
The method he introduced is designed to accomplish this and, 
at the same time, leave undisturbed all organs which appear to 
be normal or only functionally affected. In favorable cases, 
this operation leads to a permanent cure of the mastoiditis 
with only a slight impairment of the hearing and no continuing 
damage to the general health. 

As the surgeon may encounter conditions which will necessi- 
tate contact with the brain, a specially careful asepsis is en- 
joined in this operation. Sterilization of the hands and wrists 
of the operator and his helpers and also of all instruments and 
dressings must be thorough. All hair is to be shaved from 
the operative area and from a two-inch margin surrounding it 
and the integument scrubbed first with soap and water and 
then with ether and alcohol; finally the side of the head is pro- 
tected, up to the moment of operation, by a covering composed 
of several layers of gauze wet with a solution of mercury bi- 
chloride, 1 to 5000. The position of the surgeon is at the head 
of the operating table on which the patient lies upon his sound 
side, his face turned toward the ansesthetizer, his vertex toward 
the operator and his occiput toward the assistant. 

General anaesthesia having been induced, the primary incision 
is made with a scalpel and has a curviliner course, beginning at 



,gg NOSE, THROAT AND EAR 

the tip of the mastoid process and continuing upward, a quarter 
of an inch behind the auriculo-mastoid groove, to a point per- 
pendicularly above the orifice of the external auditory meatus. 
During this procedure, the auricle is drawn forward and down- 
ward by the hand, just enough traction being made to keep it 
out of the way. Free bleeding from several minor vessels fol- 
lows this first incision, but is readily controlled with haemostats 
which are left in place till the operation is finished. The layers 
of the integument divided to the surface of the periosteum are 
drawn forward and backward and held by rake-shaped retrac- 
tors. The anterior flap, carrying with it the auricle and part 
of the cartilaginous meatus, is easily retracted, as it has a convex 
margin, but the posterior flap, whose border is concave, may 
present some difficulty. This is obviated by a short horizontal 
cut at right angles to the former incision and near its center, 
where the constriction is greatest. 

The next step is to divide the periosteum along the course 
of the former section and to lift it from the bone with an eleva- 
tor. In making both incisions the temporal fascia is carefully 
protected from injury and, when the osseous surface has been 
fully exposed, the periosteal flaps are turned to each side and, 
together with the overlying integument, held away from the 
area of operation by an automatic retractor (Fig. 121 A). 
The surface brought into view is the mastoid cortex upon which, 
as a guide, we suppose there is a trianguloid figure drawn with 
the following outline: the first side follows the incision, extend- 
ing from the mastoid tip along the rear wall of the osseous part 
of the meatus, up to the supermeatal crest; the second side 
follows the crest backward from this point and the third side 
is a line joining the other two, as shown in Fig. 122. This 
trianguloid is the base of a pyramid at whose apex is the antrum. 
The task of surely and safely opening this chamber has stimu- 
lated the invention of instruments, a complete assortment of 
which would be large and costly. There are mallets and chisels, 
conical drills and burr drills, the Russian perforator, a rasping 
drill rotated by electricity and others beside. I have not used 



MASTOIDITIS 389 

any of these instruments for a long time, because I find the work 
can be done more satisfactorily by one simple and inexpensive 
implement. This is a steel gouge, six inches in length, made in 
one piece, and having a heavy bulbous handle affording a firm 
grasp (Fig. 12 iC). It has a short shaft terminating in a 
curved cutting edge which is bevelled upon the upper, concave 




Fig. 122. — The cortex of the mastoid exposed. Trianguloid figure serving as a 
guide in penetrating to the antrum. 

surface, but straight upon the lower side which is convex. As 
this gouge is pushed forward, the convex side is in contact with 
the bone and the edge removes thin chips. It cannot go too 
deep, because the surgeon's index-finger rests in the groove of 
the shaft close to the cutting edge and serves as a constant 
guard against dangerous penetration. This precaution is an 



39° 



XOSE, THROAT AND EAR 



admirable feature of the instrument and the position of the 
finger is shown in Fig. 123. 

The bone is removed little by little, starting near the lower 
portion of the trianguloid figure and working upward, forward 
and inward, until a conical excavation is made and the gouge 
opens a cavity at the bottom of this pit. The distance of this 




Fig. 



123. — Proper position of the finger guarding the edge of Randall's mastoid 
gouge. 



cavity from the cortex is usually ten or fifteen millimeters. 
The breaking of the wall may be attended by an outflow of pus 
which has been incarcerated under pressure and, when this is 
considerable, the inference is that the cavity opened is the an- 
trum; indeed the method detailed reaches the antrum in a great 



MASTOIDITIS 



391 



majority of cases, but occasionally the gouge may first pene- 
trate some contiguous cell and, to arrive at certainty, a thin 
silver probe, bent near the end, should be passed into the open- 
ing just made and its point directed toward the tympanum. 
If it enters the attic we are assured that it has passed through 
the antrum upon its way thither. Should the first cavity 
opened prove to be a cell, the antrum will be found by a little 
further excavation. The work of the gouge is supplemented 




Fig. 124. — The antrum and mastoid cells converted into one cavity with two 
openings. Schwartze operation. 

by the use of rongeur forceps (Fig. 121D) with which the rest 
of the cortical layer of the mastoid is cut away and all spicules 
of bone removed. The breaking up of the cells and the thorough 
ablation of all diseased tissue and all morbid products is then 
effected with sharp curettes (Fig. 121 EE). When this work 
is finished, there will be within the mastoid a single cavity of 
variable size and shape which, if the integrity of the cranial 
partition has been maintained, will have two openings, one made 
by the operation and the other the natural passage to the tym- 
panum (Fig. 124). Sometimes a large cell is located in the tip 



392 NOSE, THROAT AND EAR 

and pus burrows downward into the digastric fossa. In [this 
condition, termed Bezold's mastoiditis, the tip must be extir- 
pated and aseptic treatment employed with drainage from both 
the upper and lower incisions; after which the somewhat extended 
incision along the neck is closed by sutures. 

Great care is taken to avoid wounding the facial nerve which 
descends through the Fallopian canal across the anterior part 
of the mastoid to the point of its emergence at the stylomastoid 
foramen, and also not to break the partition dividing the mas- 
toid cells from the lateral sinus. If this mishap occurs, a gauze 
plug may be inserted till the operation is complete, when the 
ruptured spot can be covered with a pad retained in place by 
the antral packing. Extradural abscess, sinus thrombosis, 
meningitis and brain abscess are complications which may be 
discovered during the operation and, when found, demand 
immediate treatment. See Chapter XXXV. 

After all deleterious substances have been removed from the 
cavity remaining within the mastoid, the raw surface should be 
irrigated with a solution of mercury bichloride (i to 5000), and 
a gauze packing introduced both as a means of drainage and 
to promote healthy granulation. The periosteum is then re- 
placed and the incisions closed by interrupted sutures, a suffi- 
cient space near the center being left unsutured to afford com- 
mand of the drainage and provide for the removal of the packing 
when it is no longer needed. If exuberant granulations appear 
they should be reduced with a solution of silver nitrate: oj 
ton. §j, or snipped off with scissors, a procedure which is not 
painful. 

Another method of postoperative treatment consists in 
cleansing the cavity as already described, and then allowing 
it to fill with blood, the capillary flow being incited by very 
gentle friction of the denuded surfaces. This blood coagulates 
and over it the tissues are replaced and sutured, an aperture 
filled with a wick of gauze being left at the lower margin of the 
wound. In favorable cases the clot becomes organized and 
serves as a matrix for the deposition of other reparative material, 



MASTOIDITIS 393 

shortening the time required for recovery and improving the 
appearance of the region after convalescence is complete. 

The process of repair after the operation is usually slow and 
during this time the operative area must be protected by a light 
covering of sterile gauze, kept in place by a roller bandage 
or by a well-fitting cap of linen or muslin. We cannot regard 
the cure as accomplished until healing is perfect at every 
point, and there is entire cessation of pain, tenderness and 
ottorrhoea. 

The radical mastoid operation has developed from the pro- 
cedure which was devised by Stacke, and the modification, 
perfected by much experience and now very generally preferred, 
is termed the Stacke-Schwartze operation. It requires both 
caution and skill, for the brain and lateral sinus are in close 
proximity and the surgeon cannot know in advance whether 
the protective anatomical barriers are intact or not. As most 
of the auditory conducting mechanism is removed by the opera- 
tion, it leaves only a fraction of the functional power of the mid- 
dle ear. Nevertheless if the internal ear remains normal, there 
may be improvement in the hearing actually possessed by the 
patient, due to removal of diseased and necrotic structures 
which had not only lost all functional value but were an ob- 
struction to the atmospheric vibrations reaching the tympano- 
labyrinthine wall. But conservation of the hearing is a second- 
ary motive for the radical operation, its main purpose being 
to avert the danger of intracranial disease or general sepsis 
caused by an injurious suppurative process which has proved re- 
fractory to other treatment. It is therefore indicated in cases 
where medicinal measures, ossiculectomy and the simple mas- 
toid operation have failed to effect a cure, and also in those 
which have progressed to a late stage without operation, and 
exhibit a combination of grave morbid conditions. These 
conditions include the presence of cholesteatomata, of polypi, 
of recurrent exuberant granulations, of fistula' in the osseous 
portion of the meatus and of suppurative labyrinthitis. 

The preparation of the patient, the anaesthesia and the posi- 



394 NOSE, THROAT AND EAR 

tions of the surgeon and his assistants are the same as in the 
Schwartze operation and the instruments suited to the pro- 
cedure are shown in Fig. 125. 

The primary incision begins at the mastoid tip and extends 
upward over the course already described in the Schwartze 
technique, but is carried further to a point a little behind the 
temporal artery. Above the superior pole of the external au- 
ditory meatus the cut goes no deeper than the temporal fascia, 
but from this point downward to the tip, it extends to the bone, 
thus exposing to view the mastoid cortex. The cutaneous and 
periosteal layers are deflected from the line of incision and held 
out of the way. The next step is to separate from the superior 
and posterior walls of the bony meatus the skin and periosteum 
with a blunt-edged dissector (Fig. 125I) all the way to the mem- 
brana tympani or, if it has been destroyed, to the tympanic 
ring, and to have them properly withheld by retractors (Fig. 
125G). As the auricular flap made by the primary incision 
carries with it the cartilaginous portion of the meatus, it is now 
possible to inspect the canal and the tympanic cavity quite 
fully by rays of light reflected from the head mirror and to de- 
termine what is morbid and what is still normal throughout 
the space. 

The antrum is uncovered and entered by the technique al- 
ready detailed (Schwartze operation) and rongeur forceps (Fig. 
125D) employed to cut away the superior-posterior wall of the 
osseous meatus. For the protection of several delicate struc- 
tures — the facial nerve, theintratympanic prominence caused by 
the horizontal semicircular canal, the round window and the 
oval window with the implanted foot of the stapes — some opera- 
tors use the Stacke protector (Fig. 125 J) which is introduced 
through the antrum so that its curved extremity passes through 
the aditus into the attic and serves to shield from injury the 
structures enumerated. By the procedures which have been 
described, the antrum, aditus, attic and cavum tympani are 
converted into a single cavity, larger than the combined cham- 
bers which it replaces, because at different points osseous and 



MASTOIDITIS 



395 



other tissues have been ablated (Fig. 126). A hawk-bill curette 
(Fig. 125L) is now inserted to ablate the scutum and to remove 




Fig. 125. — -Instruments for the radical mastoid operation. (Stacke-Schwartze.) 
A, Allport's mastoid retractor; B, periosteal elevator; C, Randall's gouge; D, 
Jansen's mastoid rongeour forceps, double curve; E, E, McKernon's mastoid 
curettes; F,F, Volkmann's mastoid retractors; G, Neumann's auricular retractor;- 
//, Hartmann's mastodi rongeur; I, Allis's blunt dissector; J, Stacke's mastoid 
protector; K, Randall's extra-dural curette; /.. Randall's hawk bill curette; M, 
Randall's jugular bulb curette. 

all necrotic bone and diseased tissue, together with whatever 
products of morbid action may remain in the field of operation. 



396 NOSE, THROAT AXD EAR 

The inside of the tympanic orifice of the Eustachian tube is 
scraped with the small curette upon one end of the hawk-bill 
instrument and this curettement requires caution, as the internal 
carotid artery lies in close proximity. 

The remaining steps of the operation have reference to re- 
covery; their purpose is to secure repair of the lacerated struc- 
tures with a minimum of deformity and to preserve whatever 
remnants of functional power still exist. The cartilaginous 
part of the external auditory meatus is slit through its posterior 
side from the concha to its other end, where it joined the osseous 




Fig. 1 26. — The antrum, tympanum and intervening cavities are converted into 
one. The auditory canal is held by Neumann's retractor. 

part, the line corresponding with the longitudinal opening al- 
ready made in the bony section of the canal (Fig. 127). At 
right angles to this slit there is made a short incision separating 
the concha and meatus. In this way are formed two rectangu- 
lar flaps, comprising all layers of tissue belonging to this portion 
of the meatus (Fig. 1 28) . If in any part these flaps are too thick 
for the position they are designed to occupy, the cartilaginous 
layer may be shaved away; but the skin must be preserved, as 
it is the essential thing in the plastic results desired. 



MASTOIDITIS 



397 



After bleeding has been stopped and any necessary ligatures 
applied, the cartilaginous part of the meatus is implanted into 
the bony portion, the flaps coming into apposition with the de- 
nuded surfaces of that section of the canal and also with the 
borders of the antral cavity as enlarged by the operation. The 
skin flaps thus cover a part of the raw tissue and also, by their 
proximity, encourage the growth of a cutaneous covering over 



fs Pi 


\M_ 




' PI 


» r -^~TT" JT^"* ~»gr— iiimiii mi 

f& 1 '• ■mm) 



Fig. 127. — Slitting of cartilaginous part of the external auditory canal. 



the contiguous granulating surfaces. They are retained in the 
correct position by a tampon of iodoform gauze, reaching from 
the concha to the tympano-labyrinthine partition and so packed 
as to snugly fill the canal and keep it in proper shape. The 
cavity in the mastoid is filled with a similar packing of gauze 
and the membranes, cutaneous and subjacent, which were de- 



398 



NOSE, THROAT AND EAR 



fleeted by retractors, are replaced and their edges sutured, a 
sufficient space being left for a protruding wick of gauze to 
provide for efficient drainage. In the absence of untoward 
symptoms, the meatal tampon should be left undisturbed for 
several days; it is through the rear wound that most drainage 
occurs and the anterior dressing is required chiefly to maintain 




FlG. 128. — The formation of rectangular flaps for plastic repair of the external 
auditory meatus. Stacke-Schwartze operation. 

the structures in normal position and to promote their uniform 
nutrition during the process of repair. When the operation 
itself has proved satisfactory and convalescence is free from 
accident there is often left a perception of sound which, while 
small, is far better than absolute deafness and the caleidic result 
is, in many cases, surprisingly good as occurring after an opera- 
tion of such gravity, as is the radical mastoid. If a natural 



MASTOIDITIS 399 

posture of the auricle has been maintained through convales- 
cence, the disfigurement is almost wholly near the postauric- 
ular groove where it can be covered by a skilful disposition of 
the hair, so that by a well-arranged coiffure women are able 
to conceal every trace of the deformity. 



CHAPTER XXXIV 
OTOSCLEROSIS 

In discussions of otosclerosis there has been considerable 
ambiguity, because authorities differed as to what are the essen- 
tial features of the disease and what are only coincident con- 
ditions. At the International Otological Congress recently 
held in Boston, efforts were made to reach an agreement and, 
as a result, we may describe otosclerosis as a chronic, morbid 
process causing permanent porosis of the bony capsule of the 
labyrinth with the formation of intraosseous cells and with partial 
or complete ankylosis of the stapes and framework of the fenestra 
ovalis; also atrophy of the nerve terminals in the membranous 
labyrinth, while the Eustachian tube continues patulous and the 
membrana tympani normal. Its chief symptoms are gradually 
increasing deafness, persistent tinnitus, psychic depression and 
intermittent pain, which is not generally severe. On account of 
increased vascularity, the promontorium assumes a red color 
and this is seen through the membrana tympani at the site of 
the umbo. This sign is sometimes absent; when present, it has 
much diagnostic value. 

Two views are held regarding the pathology. One is that 
the morbid condition begins in the middle ear and extends by 
way of the blood vessels to the medullary spaces of the osseous 
labyrinth, causing inflammation of a rachitic type, which in- 
volves the stapediovestibular articulation and may affect 
all the joints in the ossicular chain. The other opinion is that 
the disease starts in the bony labyrinth by the interposing of 
periosteal cells in the Haversian canals; that the original bone 
substance is absorbed and its place supplied by a structure that 
is of harder consistence and incorporates many minute cavities, 
an alteration which has been termed spongification. The mor- 

400 



OTOSCLEROSIS 401 

bid changes, whatever their origin, render the labyrinth less and 
less able to perform its functions and, in accordance with the 
part affected, destroy the power of hearing or that of maintain- 
ing equilibrium. 

The etiology of otosclerosis is in doubt; but causes of a local 
origin play a very subordinate part. Some cases have been re- 
ported where the disease followed traumatism but such instances 
are rare and, even in the few recorded, it is possible that the 
trauma was merely antecedent, not causal. The disease is nearly 
always bilateral and occurs much oftener in females than in 
males (the Munich statistics show a ratio of two to one) . Many 
otologists claim that heredity is an important etiologic factor, 
but this is denied by others of equal authority. A considera- 
tion of all the facts leads to the conclusion that the disease has 
some predisposing cause which is constitutional, not local. 
What that cause is we do not know. Some authors lay the re- 
sponsibility upon neurasthenia, others upon the rheumatic and 
gouty diathesis, but the majority who propose an etiologic, 
theory, bring forward the conventional scape-goat, syphilis. 1 
Considering the protean forms in which the venereal disease 
manifests itself, perhaps they are right; but the morbid anatomy 
of otosclerosis differs so much from that of the familiar syphilo- 
pathies that the suggestion receives little support from analogy. 
It is worthy of further investigation, yet its bearing on the con- 
dition of any patient belongs to the esoterics of the medical 
profession for even the slightest intimation that an individual's 
deafness is due to syphilis may have evil consequences. 

The onset of this disease is so insidious that it has usually 
made considerable progress before the patient's attention is di- 
rected to it and it comes under professional notice; hence we 
know hardly anything of its exciting causes. Whatever they 
are, they do their work unobserved and the period of their ac- 
tivity is not remembered. Many authorities agree that certain 

1 The ancient adage calls war the last argument of kings (bellum, ultima ratio 
rcgum) and one might well add a new proverb to the common stock, by saying 
that— Syphilis is the final etiologic conjecture of pathologists. 
26 



402 NOSE, THROAT AND EAR 

conditions aggravate the symptoms but that is quite a different 
thing from causing them. During the course of the disease, 
exacerbations are liable to accompany attacks of the infectious 
fevers, and many other acute maladies, also parturition and the 
puerperal state. To this list the German authors add sexual 
intercourse. The special severity of the symptoms declines 
with the subsidence of the cause which produced it, but the 
patient does not regain his former status; he suffers permanent 
detriment; the deafness is somewhat worse than before; the 
tinnitus more annoying; hence every precaution should be taken 
to prevent these exacerbations. 

Otosclerosis exhibits some peculiar features, which though at 
present inexplicable, may in the future throw light upon its real 
nature. Its insidious beginning is usually in the period between 
twenty and fifty and, unlike the majority of diseases, its progno- 
sis is worse in the younger subjects, in whom recuperative power 
is greatest. In persons who are not attacked until the decline 
of life, progress is apt to be very slow and to be interrupted by 
long periods of quiescence. In this paradoxical feature it re- 
sembles diabetes. The progressive deafness is often associated 
with the curious phenomenon termed paracusis Willisii, the 
ability to hear better in a noisy place, like a railroad car, or 
crowded street, than in a quiet room. The tinnitus, which is 
frequently very distressing and may lead to melancholia of the 
suicidal type, has strange peculiarities : a patient who had never 
seen a great waterfall and tried vainly to explain a subjective 
noise, which she heard habitually at night, made a visit to 
Niagara Falls and at once recognized the roar of the cataract 
as identical with the sound which had long distressed her. 
Sometimes a nervous shock brings a total and permanent ces- 
sation of the tinnitus, a thing so incredible, if the symptom was 
due to structural change in bone, that it casts doubt upon the 
diagnosis. Giddiness, staggering, nausea and vomiting; symp- 
toms signifying disorder in the static labyrinth; are observed in 
some cases, but they are rare as compared with the surdity and 
tinnitus referable to disease of the cochlea and other parts of the 



OTOSCLEROSIS 403 

acoustic mechanism. The authorities sapiently "explain" this 
by saying that the auditory labyrinth is more vulnerable than 
the static labyrinth, which is no explanation at all, but only a 
restatement of the phenomena in different words. 

The diagnosis is made by a process of exclusion. When a 
patient shows impairment of hearing for the tones of low pitch, 
combined with tinnitus, the middle ear is examined. If the 
Eustachian tube is patulous, the integrity of the drum-head pre- 
served and the mastoid normal, the conclusion is obvious that 
there is trouble with the ossicles or the labyrinth or both. 
When upon further examination we discover fixation of the foot 
of the stapes and that the auditory defect applies to tones of 
high pitch, as well as low, we have a combination of symptoms 
and physical signs pointing to otosclerosis and their signifi- 
cance is emphasized by the absence of symptoms pathogno- 
monic of labyrinthitis. 

The prognosis, as it concerns life, is favorable, fatal termina- 
tions occurring only in a few cases where the distress over loss 
of hearing and the depression caused by uncontrollable tinnitus 
has led to insanity. In regard to hearing, the outlook is gloomy. 
Many believe that the disease advances at a variable rate and 
with intervals of quiescence, until it wholly destroys the sense 
of hearing, and that treatment can do nothing more than retard 
this advance and prolong the periods of remission. Hence they 
advise an early recourse to instruction in lip-reading. A less 
pessimistic view is held by Bezold, whose opinion has special 
value, as he has probably seen more of the disease than any one 
else, having observed more than a thousand cases during the 
years from 1880 to 1905. He is sceptical as to treatment and 
thinks that the damage done to the labyrinth is always beyond 
any possibility of repair, but he believes that in a majority of 
cases the morbid action stops spontaneously at a point short of 
absolute surdity. The patient is very hard of hearing and can 
engage in conversation only by the aid of an audiphone, but he 
is not "stone deaf," and the remnant of audition he possesses 
when the arrest of the disease occurs, that remnant he retains 



404 NOSE, THROAT AND EAR 

for the balance of his life. There is even an apparent improve- 
ment due to the tolerance established in this, as in many other 
conditions, where recovery is impossible, also to practice with the 
audiphone bringing skill in its use and hence better results. So 
it comes to pass that, although acoustic tests show none of the 
lost auditory power to have been recovered, the patient actually 
gains in f acility for communicating with his fellow-beings and, in 
that sense, really improves. Bezold very wisely lays stress upon 
the great influence such a hope exerts upon the mind, when it 
comes with the authority of a trusted physician. To one who 
fears the total loss of a special sense, even this expectation is a 
boon. 

Among the therapeutic measures recommended, either to pal- 
liate symptoms, or to retard the advance of the disease, sojourn 
or residence in the mountains has had many advocates, who 
claim that the rarefied air and other climatic conditions found 
in elevated regions are positively beneficial. Other observers 
assert that, aside from the encouragement following change of 
scene and novel experiences, there are no appreciable results. 
Mechanical treatment, which maintains the motility of the os- 
sicles by giving them exercise, has been strongly advised by those 
who believe that such exercise will prevent the ankylosis of the 
foot of the stapes in the oval window, one of the detrimental 
organic changes caused by the disease. The exercise move- 
ments are produced by the Delstanche rarefactor which causes 
an alternation of positive and negative atmospheric pressure 
or by the Lucae aural probe with cup-like extremity, which 
applies force to the short process of the malleus imbedded in 
the membrana tympani, whence it is transmitted to the other 
ossicles. The mechanical treatment is endorsed by able otolo- 
gists and condemned by others of equal standing. Among 
medicines which have proved useful are potassium iodide and 
mercury, given for their alterative effect and to combat any 
syphilitic influence possibly existing: thyroid extract and small 
doses of phosphorus (J^oo grain) have the recommendation of 
some authors, but the remedy which has the most positive 



OTOSCLEROSIS 405 

testimony in its favor is pilocarpine. At an early stage of the 
disease, when there is congestion and active histogenesis, the 
depletory effect of this powerful sudorific appears to positively 
retard the morbid changes and sometimes even arrest them. 
It must be administered in doses large enough to show its 
physiological effects to a mild degree. 

I think that otosclerosis is much less prevalent in this country 
than upon the European continent. This opinion is founded on 
my personal observation and on the paucity of American 
statistical reports. Our authors generally base their considera- 
tion of the subject upon Continental experience and refrain from 
giving tabulations or percentages of their own work, creating 
the impression that the number of cases is too small to justify 
generalizations. The statistics found in the text books have been 
collected and compiled chiefly by the otologists of Switzerland, 
Austria and Bavaria. A very useful service can be rendered by 
some one who will devote the time to gather from our hospital 
and dispensary records all information relating to this disease. 
These data would furnish a basis upon which to calculate its pro- 
portional frequency in the United States. If its ratio to popu- 
lation should be found much less than in central Europe, we 
would have a starting point for inquiring what differences in 
national environment produced the difference in prevalence and, 
from this, might proceed to a discovery of many things which 
have so far eluded search and have made otosclerosis one of the 
enigmas of modern medical science. 






CHAPTER XXXV 

INTERNAL EAR DISEASES 

The elaborate and complex mechanism of the internal ear, or 
labyrinth, has proved a very difficult subject of study from both 
the structural and functional standpoints. The early anato- 
mists classified everything here found as comprised in the organ 
of hearing and the physiologists of like date assigned to the dif- 
ferent parts various conjectural functions, all connected with 
the special sense of audition. The progress of knowledge was 
gradual and it is only in recent times that we have positively 
learned that the labyrinth has two functions which are distinct 
and widely different. The power of sound perception centers 
in the cochlea, which is connected in the closest way with the 
conducting mechanism of the middle ear: the semicircular canals 
perform a wholly diverse function which concerns the body's 
relations to space and motion, particularly the maintenance of 
equilibrium . Theuseof some accessary portions of the labyrinth 
is still in doubt, but it is presumed that they play a part in 
connection with one or other of the two well-recognized func- 
tions. The terms auditory labyrinth and static labyrinth have 
been generally adopted as descriptive of the two parts of the 
organ; the first signifying the cochlea and whatever is in physio- 
logical cooperation with it; the second the semicircular canals 
and any auxiliaries they possess. 

The study of these parts is beset with very great difficulties. 
No one has ever seen a healthy, normally functionating laby- 
rinth. We may dissect the inert mass taken from the cadaver; 
we may look at a diseased, necrotic remnant exposed to view by 
a lacerating procedure, which violently interferes with the physio- 
logical processes; but these are very different things from the 
labyrinth in its normal state, instinct with vitality and perform- 

406 



INTERNAL EAR DISEASES 407 

ingjfunctions of the greatest delicacy. Of this we have no direct 
observation: we form a mental picture and can do no more, for 
the thing itself is concealed and inaccessible. Despite these 
hindrances there has gradually accumulated a body of facts 
which furnish a rational basis for the consideration of laby- 
rinthine diseases and are not lacking in practical utility. One 
of the most important facts is the high rate of mortality follow- 
ing acute diseases of the labyrinth, ranging from sixty to ninety 
per cent. This extraordinary fatality is not due to the primary 
attack per se; for when the morbid process is restricted to the 
internal ear, the death rate is not high, but to the great liability 
of the labyrinthine disorder spreading to the meninges and the 
parenchyma of the brain. On this account when the labyrinth 
is attacked, endeavors to preserve the hearing are quite over- 
shadowed by efforts to save life and our attitude is very different 
from what it is in diseases confined to the middle ear. 

Labyrinthitis is a general term covering the varied inflamma- 
tory affections of. the structure and comprehends the circum- 
scribed, the diffuse serous and the diffuse purulent forms of the 
disease, which are not separated by any definite boundaries, but 
merge into each other. Etiologically these disorders are very 
rarely primary, nearly all being secondary to disease of the 
middle ear. Sometimes they follow an acute, purulent otitis 
media, particularly one originating in scarlet fever. In these 
instances the infecting germs passing from the tympanum into 
the labyrinth are virulent and rapidly destroy not only the 
functional power, but the osseous and other tissues of the in- 
ternal ear. Such cases, however, constitute a small minority, 
by far the larger portion taking place as a result of' purulent 
otitis media in its chronic form, frequently after a continuance 
covering years. Here the labyrinthine malady itself develops 
slowly and insidiously. The avenues by which infection gains 
access are the oval and round windows, necrotic orifices in the 
osseous partition and especially fistulous openings in the hori- 
zontal semicircular canal. Tuberculosis and cholesteatomata 
play a part in a considerable number of these inflammations, 



408 NOSE, THROAT AND EAR 

by inducing a slow, but progressive destruction of the bony 
walls protecting the labyrinth. 

The symptoms, so far as they are referable to the auditory 
labyrinth, are not very significant, except the deafness. There 
is some pyrexia, particularly in connection with suppuration; 
but the fever is too slight and variable to be of much value in 
diagnosis. The same description applies to the pain and 
tinnitus. Their character is not sufficiently definite to prove 
the locality of the disease, especially as both of them occur in 
chronic, purulent otitis media, with which labyrinthitis is nearly 
always intercurrent. The surdity alone is a positive diagnostic 
sign. When one suffering from inflammation of the middle ear 
experiences a sudden and notable increase in his deafness; or 
when, after the radical mastoid operation, the remnant of sound 
perception, which is retained, becomes suddenly extinct, there 
is strong probability of labyrinthitis and the aural tests, which 
discriminate between the audition of tones of high and those of 
low pitch and between the perceptive and the- conducting mech- 
anisms, should be employed. The application of these tests, 
described in Chapter XXVIII on Aural Examinations, furnishes 
whatever information is procurable from the auditory labyrinth 
except that in patients who have undergone the radical mastoid 
operation, bringing into plain view the tympano-labyrinthine 
septum, active suppuration, overfilling all the cochlear region, 
may be manifested by pus impelled outward through fistulous 
orifices and showing itself on the exterior side of the partition. 
Such an occurrence, of course, clears up all doubts regarding the 
character of the morbid process. 

There is a group of symptoms referable to the static labyrinth 
which have a dual significance. First, their presence indicates 
(probably) a morbid condition of the semicircular canals and, 
second, implies involvement of the auditory mechanism be- 
cause the static labyrinth is much less vulnerable than the other 
and, if it has given way to disease, we infer that the aural ap- 
paratus is even more seriously affected by the same morbid 
influences. The symptoms alluded to are giddiness, nausea or 



INTERNAL EAR DISEASES 409 

vomiting and difficulty of maintaining equilibrium, especially in 
standing and walking. These things signify disorder in the 
semicircular canals, provided they are properly assignable to 
the labyrinthine region. That proviso raises a question which 
leads to a new phase of the subject. Nausea and vertigo may be 
due to causes foreign to the internal ear, e.g., to certain gastric 
disturbances; hence the question arises in each individual case 
whether these symptoms are traceable to the semicircular canals. 
To decide this question, we resort to the production of nystag- 
mus, a phenomenon of peculiar kind, which has excited great 
interest during the past decade and is a novel phase of otologic 
study attracting at the present time probably more attention 
than any other of the new subjects. So far as this phenomenon 
is used to decide whether the symptoms (vertigo, nausea, etc.) 
originate in the labyrinth or elsewhere, the matter can be dis- 
posed of in few words. When the semicircular canals are 
normal, certain stimulants excite nystagmus of a definite and 
well-recognized kind. This result does not follow if the canals 
are disabled by disease. Therefore, when a patient has vertigo 
or other suspicious symptom the stimulus is applied, and if it 
excites a normal nystagmus we infer that the vertigo is not of 
labyrinthine origin, but is caused by disorder somewhere else. 
If the normal response does not appear, we may often infer that 
the fault is in the static labyrinth. 

The word nystagmus signifies a rolling or rotation of the eye- 
ball. The ball is suspended in the orbit in such a way that this 
rotation may occur in any one of the three planes of space, and 
the ocular muscles, such as the adductor, abductor, patheticus 
and others, supply the traction to produce these forms of rota- 
tion . The semicircular canals of the labyrinth are located very 
nearly in these three planes. The horizontal canal occupies the 
position indicated by its name; the superior canal is vertical in 
direction and is placed transversely to the long axis of the petrous 
portion of the temporal bone, on the anterior surface of which 
its arch forms a round projection; the posterior canal, also ver- 



4IO NOSE, THROAT AND EAR 

tical, is directed backward nearly parallel to the posterior surface 
of the petrous bone. 

When the contents of the normal semicircular canals are sub- 
jected to excitation, there is induced a series of neural impulses, 
which cause movements of the eyes, and among these movements 
there is one quick rolling motion succeeding each form of excita- 
tion, a motion more conspicuous than the others. This quick 
motion is a rotation in the horizontal, or in one of the vertical 
planes, and its characteristics designate the form of nystagmus 
incited by that particular excitation. Thus, if a certain excitant 
causes both eyes to rotate upon their axes, toward the left, in 
the horizontal plane, we say that excitant produces binocular, 
horizontal, nystagmus to the left. 

In considering the various excitants and the ocular rotations 
which follow their use, a clear distinction must be made between 
the facts, the observed phenomena, and the theories constructed 
to explain those phenomena. The facts are well authenticated 
by many careful observations and it is with the facts that the 
clinician is chiefly concerned. There is a spontaneous nystag- 
mus, whose nature has been minutely studied by neurophysi- 
ologists; but for diagnostic purposes the artificially excited 
nystagmus is generally used, because our ability to control it 
renders its manifestations more uniform and hence more in- 
structive. The methods of artificial production comprise the 
caloric test, the rotation test and the mechanical test (in the 
presence of fistula). There has also been discovered a gal- 
vanic reaction, when the electro tonus is disturbed; but it is 
merely corroborative of the results given by the other methods. 
The caloric test is the most sensitive, that is to say, the response 
which it elicits from a normal labyrinth is suppressed by a milder 
disease than other responses. It is performed by syringing the 
external auditory meatus with water at two temperatures, sepa- 
rated by an interval of forty-five thermic degrees F. When the 
temperature of the water is 115 F. its injection is followed by a 
nystagmus to the same side as that upon which the syringe has 
been used and when the temperature of the water is 70 F. there 



INTERNAL EAR DISEASES 



411 



ensues a nystagmus to the opposite side. The temperature of 
the warm and cool water is from 15 to 30 above or below the 
normal standard of the body, but the actual thermic change in 
the semicircular canals is considerably less than on the surface 
of the membrana tympani, on account 
of loss during transmission through the 
intervening structures. 1 

In the rotation test the whole body, 
either erect or in the sitting posture, 
is turned around ten times, all the 
whirls being in one direction. After 
the motion ceases there is nystagmus 
to the opposite side. A special chair 
devised for making this test is shown 
in Fig. 129. 

The fistula test presupposes the exist- 
ence of a fistulous opening between the 
cavity of the tympanum and the laby- 
rinth and also a perforation of the drum- 
head. Inflation of the tympanum is 
produced by a pneumatic bulb, such as 
a small Politzer bag, whose nozzle is in- 
troduced into the meatus and sur- 
rounded with cotton or other packing 
which prevents the external escape of 
the air. Compression of the bulb causes 
condensation in the tympanum and pro- 
duces, through the fistula, pressure upon 
the contents of the horizontal semicir- 
cular canal. The result of this manceu- 
ver is nystagmus to the same side — the side with the fistula. 

The knowledge that the three tests described are normally 
1 The mnemonic syllable, cows, beginning with the same letter as caloric (C), 
may aid in remembering the result of the caloric test. Express that result in 
the sentence "cool water turns to opposite side, warm water turns to same side"; 
then put together the initial letters of the four adjectives used, i.e., cool, opposite, 
warm, same; giving the word, cows. 




Fig. 129. — Rotating chair 
complete with douching at- 
tachment. 



412 NOSE, THROAT AND EAR 

followed by the various forms of nystagmus which have been 
specified, enables us to employ this ocular phenomenon in di- 
agnosis. It aids us in correctly interpreting the significance of 
vertigo, nausea and unstable equilibrium and absence of nystag- 
mus after application of the tests, indicates a nearly complete 
loss of function in the static labyrinth. From a clinical stand- 
point, the help nystagmus gives in diagnosis is its chief, almost 
its sole, value and, since this value is in no way dependent 
upon the hypotheses concerning it, but simply upon the well- 
proven facts, an exhaustive theoretical discussion is not necessary 
in a treatise like this whose paramount purpose is to assist the 
clinician. Readers who desire to pursue a detailed study of the 
subject can find lengthy and elaborate dissertations in the 
works of the European otologists, especially those of Vienna. 
They will also find many pages devoted to its consideration in 
American books whose authors have closely copied the Austrian 
writers. For our present purpose it will be sufficient to give an 
outline of the hypothesis that is generally accepted as explana- 
tory of nystagmic phenomena, and to illustrate this by a 
single example which, for the sake of simplicity, is the horizontal 
nystagmus induced by the rotation test. 

It is held that the rolling of the eyeball is due to neural im- 
pulses, the first of which starts in the motion of cilia upon the 
inner surface of the semicircular canals. These cilia are bent 
to and fro by currents which agitate the endolymph, hence the 
usual statement of the phenomenon is that movement of the 
endolymph originates the primary neural impulse affecting the 
eye. Moreover, the lymph-started impulse acts only in the same 
spatial plane in which it originated, e.g., an endolymph current 
in the horizontal canal gives rise to an impulse which causes 
the eye to turn in a horizontal plane and in that plane only. 
This turning of the eye starts a neural stimulus which, traversing 
a pathway leading to the cortex of the cerebrum, excites an oc- 
culomotor center there located and this center sends forth a 
second impulse antagonistic to the first and of greater power. 
This second neurokyme is termed the cortical impulse. 



INTERNAL EAR DISEASES 413 

Let us now apply these principles to the phenomenon following 
rotation of the body which, as already stated, is a nystagmus 
to the side opposite the direction of the turning. The patient 
with head erect is seated in a pivot chair which allows free 
circular movement in the horizontal plane. His body is turned 
around ten times toward the right, the direction in which the 
hands of a watch move, when the dial is uppermost (dextrad 
rotation). The endolymph in the two horizontal canals par- 
ticipates in this motion. That contained in the other canals is 
not affected. When the body's rotation stops, the endolymph 
continues to move by virtue of its physical property called " the 
inertia of motion," until it gradually comes to a state of rest. 
Thus there is produced a lymph current which in the right-hand 
canal flows from the ampullar end toward the small end and, by 
so doing, starts a vestibular impulse causing a slow horizontal 
rotation of the eye toward the same side, a dextrad turning. 
This turning of the eye excites in the brain a cortical impulse, 
which antagonizes the vestibular impulse and, being stronger, 
reverses the former's effect, hence the slow rotation of the eye 
above mentioned is promptly followed by a quick rotation in 
the opposite direction, sinistrad turning, and this quick motion 
is designated as the nystagmus produced by the turning test. 
At the same time, a lymph current in the left-hand canal is 
flowing from the small end toward the ampullar end and, by so 
doing, starts a vestibular impulse causing a slow rotation of the 
eye toward the opposite, right side. The cortical impulse ex- 
cited by the stimulus originating in the eye motion reverses this 
effect and causes a stronger, faster rotation in the contrary 
direction; that is, a sinistrad turning, a quick motion designated 
the nystagmus. From the foregoing statements it follows that, 
when the endolymph is put in motion by the rotation of the 
whole body to the right in the horizontal plane, the actions tak- 
ing place in both of the horizontal semicircular canals cooperate 
in exciting neural impulses which bring about a sinistrad, hori- 
zontal nystagmus, which affects both eyes and is clear and dis- 
tinct, since in the final phenomenon all the forces act together 



414 NOSE, THROAT AND EAR 

without counteracting factors. Similar theoretical explana- 
tions have been worked out for the other nystagmic manifesta- 
tions and they are very ingenious but they do not add anything 
to the empirically acquired information already possessed, the 
facts which are an aid in diagnosis, nor can they give us any 
help in therapeutics. 

When we are dealing with an inflammation of the inner ear, 
affecting the auditory labyrinth, or both it and the static mech- 
anism, we confront morbid conditions of the most serious kind, 
and the region affected is so difficult of access that our ability to 
modify and improve these conditions is very limited. If the 
labyrinthitis is of the circumscribed type it may spontaneously 
disappear by a process of gradual devitalization leaving perma- 
nent impairment of the hearing to a greater or less degree. 
This, though not recovery, is the most favorable termination we 
can anticipate and there are no therapeutic measures by which 
its occurrence can be promoted, except possibly antifebrile 
constitutional treatment, whose value is doubtful. When the 
disease is of the suppurative type, or reaches the purulent stage, 
the delicate mechanism of the cochlea is hopelessly disorgan- 
ized and destruction of the hearing becomes inevitable. The 
prognostic problem ceases to be one of preserving an invaluable 
special sense and becomes one of preventing the patient's 
death. To ward off intracranial complications is the urgent 
demand of the situation and the best hope of doing this appears 
to consist in making a free vent for the purulent fluid on the 
exterior side of the labyrinth, opening all receptacles which 
might retain it and rendering the emptied cavities as aseptic as 
possible, at the same time saving, to the best of our ability, in- 
terior walls which may still serve for the protection of the 
meninges. 

It was to accomplish these results that the Hinsberg operation 
was devised. It is performed under general anaesthesia and is 
divisible into five stages. The first is identical with the radical 
mastoid (Stacke-Schwartze) operation and takes away every- 
thing which must be be removed as far as the tympano-labyrin- 



INTERNAL EAR DISEASES 415 

thine septum. The second penetrates this partition, gaining 
access to the internal ear. The ledge of bone overhanging the 
anterior margin of the facial ridge is clipped off with cutting 
forceps, the stapes is extracted by a movement combining slight 
traction with oscillation and the round and oval windows are 
turned into one by breaking up the intervening bone; epineph- 
rin chloride, in a solution of one in two thousand, is then ap- 
plied to the labyrinthine surfaces with a small swab of cotton in- 
troduced through the opening thus enlarged, so as to secure 
ischaemia during the subsequent procedures. In the third stage, 
the vestibule is opened up in a way to provide for its thorough 
drainage. The upper part of the prominence of the horizontal 
semicircular canal is uncovered by removing the spongy super- 
imposed bone in thin shavings with a small, sharp gouge. 
When the ampulla is exposed, it is opened from above, a free 
vent being made by cutting away nearly half of the bulbous 
tube but leaving the lower part of the sheath intact. Through 
the opening into the vestibule its interior should be explored, 
visually and with a probe, and any necrotic bone or other 
morbid product removed. In the fourth stage the auditory 
labyrinth is subjected to dissection similar to that just per- 
formed in the static portion, the object in both cases being re- 
moval of diseased tissue and subsequent drainage. The 
promontorium, which is formed by the lowest part of the cochlea, 
must be removed and to reach it some further shaving of con- 
tiguous bone may be necessary, but normal osseous tissue is 
spared as far as possible. When made accessible, the promon- 
torium is ablated with the gouge, laying bare the larger end of 
the cochlea. The first whorl of this structure is now cut away, 
the integrity of the remainder being preserved. With this pro- 
cedure upon the cochlea, the Hinsberg operation is virtually 
complete, the fifth stage having reference entirely to repair of the 
lacerated tissues. Sterile gauze packing is employed to fill the 
cavities left in the internal ear and this packing connects with 
that in the tympanic and antral spaces whose postoperative 
treatment in connection with the Stacke-Schwartze method is 



41 6 NOSE, THROAT AND EAR 

set forth in Chapter XXXIII, where description is given of the 
plastic technique and of other steps which are equally applicable 
after the Hinsberg procedure. 

Regarding end results, it may be said that the consequences 
of operation upon the labyrinth are very similar to those ob- 
served in the spontaneous subsidence of a circumscribed laby- 
rinthitis accompanied by abolition of auditory function, except 
that there is some disfigurement due to the surgical measures 
employed. Aside from this we have in both cases total deafness 
on the affected side, but little impairment of static control 
which tends to regain nearly normal conditions in course of time, 
and usually but little tinnitus and no impairment of constitu- 
tional vitality. The operation is credited with saving life in 
many cases of severe purulent labyrinthitis. 

Brief reference should be made to some occupational affec- 
tions of the internal ear. "Boilermakers' deafness" is due to 
the continuous succession of strong vibrations caused by driving 
and clinching rivets in boilers and in the steel beams and girders 
used in erecting high buildings. It produces some hyperplasia 
of the drum-head, but does most harm to the cochlea. Its 
progress may be retarded by wearing an auricular hood filled 
with cotton or inserting in the meatus a tiny rubber bag con- 
taining alcohol, but the only sure prophylaxis is change of 
occupation. 

The caisson disease is caused by working in compressed air, 
used in laying the foundations of bridges and in tubes at the 
bottom of rivers. It affects the entire body but the damage to 
the labyrinth is due, not so much to the compressed air itself, as 
to a sudden change from it to an atmosphere of normal density. 
Under pressure an unusual proportion of air is absorbed by the 
plasma of the blood and when the pressure is suddenly removed, 
this absorbed air separates from the blood in bubbles. Ordi- 
narily the coats of the veins and arteries can bear this centrifugal 
pressure, but it does irreparable damage to the delicate struc- 
ture of the cochlea. The danger can be obviated by a gradual 
decrease in the density of the atmosphere, such as is effected by 



INTERNAL EAR DISEASES 417 

interposing two or three reduction chambers between the com- 
pressed-air room and the entrance shaft where there is the aver- 
age outside pressure. The air density is successively diminished 
in these chambers and passage through them causes the pres- 
sure within the body to approach the normal standard, before 
the outer atmosphere is reached. 

The violent vibrations caused by the firing of cannon 
may rapidly injure and even destroy the hearing, though 
there is much variation in the resistance offered by different 
individuals. This danger has been augmented in recent 
times by the increased size of the guns used in field artillery. 
Soldiers have devised a method of prophylaxis which seems 
to have escaped, the notice of writers on otology. Veterans 
advise new recruits to save their hearing by looking directly at 
the muzzle of cannon being fired. The posture thus given to 
the head greatly weakens the atmospheric impact upon the 
drum-head, for the vibratory waves radiate in every direction 
from the gun's muzzle and those passing by the observer's 
face impinge against the tragus and slant off past the anti- 
tragus and helix, exerting far less force upon the membrana 
tympani than if they had penetrated the external auditory 
meatus in a straight line. Yawning at the moment the gun 
is discharged lessens the liability to injury by equalizing 
pressure. 

In what has been said of the static labyrinth, I have assumed 
the correctness of the generally accepted theory which assigns 
to it gubernatorial functions regarding the body's equilibrium 
and relations to space and motion; an hypothesis, which 
involves principles of sciences distinct from physiology, es- 
pecially the laws of physics and mechanics. This theory has 
been adopted by most otologic authorities and it serves as an 
explanation of symptoms and other phenomena and hence is 
an aid in clinical study. Nevertheless the reader should 
be apprised of the fact that it does not rest upon very solid 
ground. Prof. Neumann, in his writings and especially in 
his oral instructions to our class, taught that we might antici- 
27 



41 8 NOSE, THROAT AND EAR 

pate gradual amelioration of vertigo and other symptoms, 
even when incurable disease of the labyrinth was steadily, 
though slowly, advancing. He showed that as the internal 
ear became less and less responsive to stimuli, the symptoms 
tended to subside, and he reasoned that when the disease had 
finished its injurious work and the labyrinth had become an 
inert mass, this subsidence would be complete. His state- 
ments were doubtless entirely correct; but neither he nor 
others appear to have pursued this line of reasoning to its 
logical conclusion, nor shown its ultimate effect upon the 
doctrine of the physiology of the static labyrinth. If the 
internal ear upon one side is functionally dead, whence comes 
the regulation of equilibrium? It will be answered that the 
normal organ on the other side does double work, just as 
after a nephrectomy the remaining kidney takes up the task 
of the one removed. But even when both labyrinths have 
become functionless, precluding such compensation, the sub- 
sidence of symptoms still takes place. Moreover, necropsies 
have shown that in certain deaf mutes there were non- 
functionating labyrinths from the time of birth or early in- 
fancy, and yet many of these mutes had not exhibited any 
notable abnormality in regard to equilibrium or the spatial 
relations. 

Equilibrium and motion in space depend upon three things: 
the vestibular apparatus, sight, and the muscular sense which 
recognizes the direction and force of gravitation. Some aid also 
is given by the tactile sensations. Under normal conditions 
the stability of the body is comparable to that of a tripod. 
Balance can be maintained by voluntary effort when any two 
of the functions are normally performed, as is the case in 
the dark or when the eyes are closed, conditions in which no 
assistance is given by the ocular sense. It is hardly possible 
for one function alone to maintain equilibrium. Disease of 
the labyrinth disturbs balance and confuses spatial relations 
by giving rise to variable and false impressions. When the 
labyrinthine function has been entirely abolished, this dis- 



INTERNAL EAR DISEASES 419 

turbing element is eliminated and equilibrium regains a fair 
measure of stability through the cooperation of the two re- 
maining functions. 

The excitation of the semicircular canals giving rise to vertigo 
and nystagmus and thereby eliciting certain phenomena, which 
have diagnostic value, has been considered in a former part of 
this chapter, where the influence of rotation upon the horizontal 
canals is explained as an illustration. 

Quite recently the utilization of canal-excitation for diagnos- 
tic purposes has been greatly extended by the introduction of a 
procedure termed past-pointing, which is novel both in its 
action and in the object to be attained. The discovery of this 
diagnostic sign is credited to Barany, the otologist of Vienna. 
Some Philadelphia physicians who were sojourning abroad 
made themselves familiar with the subject and, when they re- 
turned home, undertook to impart their information and to 
repeat and develop the work done in Vienna. Through their 
influence a department of Neuro-otology was established in 
the University of Pennsylvania and facilities furnished to thor- 
oughly study past-pointing, nystagmus and cognate subjects. 
In the group of able men, who have promoted the success 
of this new departure, Dr. Isaac H. Jones is conspicuous for 
his earnest and assiduous labors. By giving me information of 
the highest value he has placed me under an obligation which I 
most gratefully acknowledge. 

In discussing a subject like past-pointing which is not only 
new but somewhat abstruse and difficult, we should strive to 
secure absolute clearness and plainness of statement. Ambi- 
guity is often caused by using the same adjective to describe 
words which embody an idea of change and also words imply- 
ing stability. To avoid obscurity of this sort, 1 shall restrict 
the use of normal to such terms as process, reaction, transmis- 
sion; while employing healthy to describe organ, body, patient 
and similar substantives. 

The technique of past-pointing is as follows: The patient sits 
in the erect posture (occupying the special chair, Fig. 129) with 



420 NOSE, THROAT AND EAR 

right arm and forearm extended before him, the hand and index- 
linger in a horizontal line; the other fingers and thumb be- 
ing flexed in the palm. The physician sitting directly oppo- 
site has his left elbow flexed with forearm, hand and fingers 
in the posture just described. A space of six inches separates 
the knees of the two. The patient lays his extended index- 
linger upon that of the physician producing bidigital contact 
for two or three inches. The patient now closes his eyes and 
endeavors to remember as fully as possible the position of his 
linger: he then lifts the right arm to a vertical position and 
slowly brings it down to its former level trying in so doing to 
restore the bidigital contact. This effort is generally successful 
and if the patient misses the doctor's finger, which has not 
moved, he comes very close to it. If the experiment be repeated 
many times, it will be found that in a large majority of the trials 
the two index-fingers come together. This result is due to the 
fact that the patient's muscular coordination and static sense are 
able, in conjunction, to give correct guidance without the aid of 
sight. In this procedure it is presumed that the musculature 
of the patient's right arm and shoulder and the controlling 
nerves are in a fairly healthy state. 

The next step is to produce excitation of the semicircular ca- 
nals either by rotation or by thermic change. While this exci- 
tation continues there is a repetition of the movements already 
detailed from the closure of the patient's eyes till his right in- 
dex-finger drops into the horizontal plane. What happens at 
this stage must be clearly understood as it is the essential fea- 
ture of the past-pointing test. It is found that in many pa- 
tients the descending index-finger not only fails to touch the 
stationary finger of the physician, but deviates ten inches to 
the right or left. This is caused by a neural impulse, starting 
in the semicircular canals and reaching the forearm which 
diverges to one side. Those showing this deviation include a 
group of patients who neither at that time nor any other have 
presented evidence of brain disease and also a group of persons, 
not patients at all, but robust individuals submitting them- 



INTERNAL EAR DISEASES 42 1 

selves to experimentation to show what features of these phe- 
nomena are physiological and free from any pathological ele- 
ment. In view of these facts the occurrence just described 
is termed "the normal reaction in past-pointing." It is the 
usual, proper reaction following the stimulation of the canals in 
persons with healthy brains. In so far as intracranial lesions 
are concerned it gives a negative result; that is, it does not indi- 
cate either their presence or absence; for a disease might be so 
located as not to modify the reaction. 

We now turn to a group of patients, in whom excitation of the 
canals does not cause deviation in past-pointing. With closed 
eyes they are able to restore the bidigital contact, just as though 
no stimulus had been applied. It is plain that something has 
suppressed the neural impulse originating in the canals; and 
it is a clinical fact proved empirically that this group of patients 
comprises most of those affected with disease of the brain. The 
nugatory result of excitation of the canals is distinguished from 
that previously described by calling it " the abnormal reaction in 
past-pointing." 

Before endeavoring to explain the diverse consequences of 
canal-excitation, attention must be directed to the fact that 
cases in which the functions of the canals have been destroyed. 
or very seriously impaired, are wholly excluded from considera- 
tion; indeed their exclusion is implied by the very words used in 
describing the procedure; for there cannot be excitation of a 
functionless, inert organ. 

In the normal past-pointing reaction the deviation was caused 
by a neural impulse starting in the canals and traveling by a 
long route to the nerves controlling movements of the patient's 
right arm. When under identical conditions of canal-excitation 
this deviation does not occur, the only rational explanation is 
that. the neural impulse has failed to reach its destination be- 
cause of an impassable barrier somewhere upon its pathway. 
It is most unlikely that this barrier is in the nerve supply of 
the upper extremity on the right side, because any obstruction 
capable of intercepting the impulse would, in this region, man- 



422 NOSE, THROAT AND EAR 

ifest its presence by other obvious signs of nervous or muscular 
abnormality; the right arm would be considered unfit for use in 
the past-pointing experiment and the left would be substituted 
in its stead. There is very strong probability that the barrier 
exists in the centers of the nervous system, in the cerebrum, 
cerebellum or medulla. There is no doubt that a tumor press- 
ing upon the nerve constituting the passageway of the impulse 
from the canals could intercept it and likewise its normal trans- 
mission could be prevented by other brain lesions. In this fact 
consists the peculiar diagnostic value of past-pointing. The 
intercepting of the neural impulse indicates that an abnormal 
growth or a morbid process exists upon the route of transmission 
from the static labyrinth to the musculature concerned in the 
past-pointing movements. 

In accordance with the researches of Dr. Jones, it is held 
that the horizontal and vertical canals, on each side, possess 
distinct and separate pathways, or arcs, over which their im- 
pulses are transmitted. These arcs occupy specific locations in 
the intracranial region. When excitation of the canals shows 
that some of them successfully send out impulses, while others 
do not, the obstruction must be situated upon the arcs of the 
canals which fail in this act. The positions of such arcs, as far 
as known, give valuable aid in localizing intracranial lesions. 

Past-pointing promises to be very useful when conjoined with 
other well-tested procedures in solving diagnostic difficulties 
concerning disease of the cerebrum, cerebellum and medulla. 
Already the neuro-otologists of the University of Pennsylvania 
have collected a store of valuable information. They have 
collated the histories of 125 carefully watched cases, nineteen of 
which came to operation: in these instances the deductions made 
from the reactions were to a great degree confirmed by what was 
discovered during operation; likewise, in four fatal cases, the 
post mortem findings proved corroborative of the diagnosis 
made during life. 

The following condensed narratives describe methods fre- 
quently employed, reactions elicited and arcs of transmission 



INTERNAL EAR DISEASES 423 

traversed by the neural impulse between the semicircular canals 
and the boundaries of the intracranial region. The route taken 
outside of the skull is of minor importance for the purpose we 
have in view. 

No. 1. When the patient's head has been thrown backward 
(90 ) cool water (68° F.) is injected against the right drum- 
head. The normal past-pointing reaction takes place; the 
descending index-finger fails to restore the bidigital contact 
and deviates ten inches to the right. At the same time there is 
horizontal nystagmus to the left, both manifestations being 
caused by excitation of the right, horizontal canal now in a ver- 
tical position. The arc of neural transmission extends from the 
canal by way of the auditory (VIII) nerve to the triangular 
nucleus, the nucleus of Deiters and the posterior, longitudinal 
bundle. A lesion in this locality would intercept the neural 
impulse and change the normal reaction to the abnormal. 

No. 2. Warm water (112 F.) is injected against the right 
drum-head. There ensues the normal past-pointing reaction 
with deviation of ten inches to the left and nystagmus toward 
the right. The neural arc is the same as in No. 1. 

No. 3. Rotation to the right with head erect ten turns in 
ten seconds. This elicits the normal past-pointing reaction and 
the finger deviates toward the right a foot and a half. This is 
due to the simultaneous excitation of both horizontal canals and 
is accompanied by nystagmus to the left. The neural arc is 
the same as in Nos. 1 and 2, for the right side, and it passes 
through the corresponding nerves and nuclei upon the left side. 

No. 4. Rotation to the right, ten times in ten seconds, with 
head bent backward at an angle of 90 from the vertical. This 
produces excitation of the vertical semicircular canals on both 
sides. The finger deviates far to the left and in both eyes 
there is nystagmus toward the right. The neural arc in this 
case differs from those formerly described. It traverses the 
auditory (VIII) nerve and directly enters the posterior longitu- 
dinal bundle whence it passes through the middle peduncle to 
the cerebellar nuclei. 



424 NOSE, THROAT AND EAR 

To the diagnostic indications given by nystagmus and past- 
pointing must be added those furnished by the presence or 
absence of vertigo. 

In persons whose condition is normal vertigo ensues upon 
excitation of the semicircular canals, especially the stimulation 
produced by the caloric test. This vertigo may be marked by 
obvious signs, or it may be very slight causing no objective 
phenomena and manifesting its presence only in the subjective 
experience of the patient who says, " I am dizzy: I feel confused." 
Vertigo is always elicited by excitation of the canals, when the 
intracranial conditions are altogether normal; therefore the 
entire absence of vertigo, after vestibular stimulation, indicates 
that there is a lesion affecting the arcs or pathways conveying 
neural impulses from the labyrinth to the centers in the cerebral 
cortex. 

Our conclusions concerning brain lesions should be based upon 
repeated tests and a very careful collation of the results per- 
taining to each of the three diagnostic factors; nystagmus, past- 
pointing and vertigo. 

It is not possible in the present state of our knowledge to map 
out accurately all the neural arcs nor can full details of each 
method of causing excitation of the six canals be given within 
the limits of this discussion. The four cases specified indicate 
methods to be pursued in a more comprehensive study of the 
subject. Doubtless in the near future our knowledge will be 
broadened and rendered more accurate. 



CHAPTER XXXVI 

INTRACRANIAL COMPLICATIONS OF EAR 
DISEASE 

In preceding chapters there have been frequent allusions 
to the danger that diseases affecting the ear may extend 
from it into the cranial cavity, such extension constituting 
the gravest consequence or complication of aural maladies. 
The auricle and cartilaginous portion of the meatus are the 
only parts of the ear outside of the skull, all the rest being 
situated in cavities contained in the temporal bone and in- 
closed either wholly or partially by osseous walls belonging 
to its structure; yet so long as morbid processes are limited 
by the boundaries of this bone they seldom imperil life, though 
some of them greatly endanger the auditory and static 
functions. As soon, however, as the disease passes the bound- 
aries of the temporal bone and enters the cranium, the prog- 
nosis becomes much worse; the centers of vitality are subject 
to direct attack, and there is scarcely any time for the action 
of remedies or for mustering the resistant forces of the body 
itself. The probabilities are against the patient, but even 
under these adverse conditions recoveries take place, and the 
very difficulties of his task are a challenge to the skilful 
and courageous physician to use every power of his mind 
and every resource of his art in a supreme effort to win a 
victory against multiplied odds. 

Although all the complications under consideration have their 
field within the skull, there is a difference in location which 
greatly influences their prognosis. An extradural abscess oc- 
cupies a place immediately inside the bony wall, upon the 
surface of the dura mater. By its enlargement it makes an 
indentation in that membrane and also in the arachnoid and 
42s 



426 NOSE, THROAT AND EAR 

pia mater, pushing them before it and compressing the sub- 
jacent parenchyma of the brain, so that the space occupied by 
the abscess is described on the brain side by an ovoid curve 
and on the skull side by a nearly flat surface. The purulent 
content of the abscess thus impinges upon the brain and makes 
for itself a cup-shaped nidus by displacing the brain sub- 
stance, but it does not penetrate that substance nor infiltrate 
it, and this distinction makes such a great difference that 
the mortality from extradural abscess is less than ten per 
cent. It seldom endangers life except by acting as a septic 
focus. The other intracranial complications, meningitis, sinus, 
thrombosis and abscess, either cerebral or cerebellar, have a 
very high mortality. 

The process by which extradural abscess is produced by 
chronic purulent otitis media (by far its most common cause) 
appears to be the following: The prolonged suppuration leads 
to inflammation and necrosis of the roof of the tympanum, 
bringing infectious material into contact with the adjacent 
area of the dura mater. This toxic matter irritates the mem- 
brane, but at first its quantity is very small, for when necrosis 
has penetrated the bone the primary perforation is minute and 
the morbid action is very slow; hence the resistance incited 
in the dura mater is quite sufficient to thwart the disease. 
There is proliferation of plastic material, the membrane is 
thickened and the septic matter is inclosed by a fibrous wall. 
If the disease of the middle ear were arrested at this stage, 
the pathogenic material would remain encysted and per- 
haps give no trouble; but the enemy is continually reinforced, 
the necrotic orifices grow larger and the pressure against the 
retaining wall constantly increases. The wall is stretched, more 
fibrin is deposited and the barrier assumes a resilient, elastic 
character. For a while it withstands the encroachments, but 
the difficulty of making room, by compressing the brain sub- 
stance, keeps on growing and the pyogenesis continues until 
at last the balance turns in favor of the disease and nature 
is defeated. The process detailed seems to be the usual one, 



INTRACRANIAL COMPLICATIONS OP EAR DISEASE 427 

but extradural abscesses may also originate in an infected 
embolism in one of the meningeal blood vessels, without the 
agency of osseous necrosis, and the route of infection may be 
through the labyrinth. The course of such an abscess varies 
with the character of the bacterial infection upon which it 
depends, and among the germs commonly responsible for 
this complication the bacillus of influenza is peculiarly virulent. 
When it is the etiologic factor, the progress of disease is faster 
and the prognosis worse than under other conditions. 

What has been already said of the gradual process by 
which an extradural abscess is usually formed makes it plain 
that an early diagnosis is difficult, unless the condition is dis- 
covered during an operation upon the mastoid. In this 
case there may be exhibited proofs which leave no -room 
for doubt. If the surgeon upon opening the mastoid cells is 
greeted by a notable flow of pus escaping under pressure and 
if, when the surplus liquid has been evacuated, the residual 
mass shows agitation, pulsating in unison with the action 
of the heart, the cavity holding the fluid must be connected 
with an intracranial purulent mass, and the rhythmical pulsa- 
tion may be caused by motion transmitted from the carotid 
artery not far off, or may be an expression of general brain pul- 
sation. Aside from discovery during operation on the mastoid, 
the presence of an extradural abscess is a matter of infer- 
ence which is far from positive, as there are no pathognomonic 
symptoms. There is usually upon the affected side, dull head- 
ache which is nearly continuous, and this is accompanied by 
slight elevation of temperature. Unless the abscess is very 
large there are no symptoms of pressure upon trunks of sensory 
or motor nerves. Occasionally spontaneous recovery takes 
place by evacuation through the ear, the pus taking a retro- 
gressive route through the necrotic bone which was the path- 
way for infection, but this favorable termination is not frequent. 

The object of treatment is to empty and drain the abscess 
without damaging the plastic barriers which have protected 
the brain. This can generally be effected by ablating the 



428 NOSE, THROAT AND EAR 

tegmen and, after the escape of the pus, irrigating the cavity 
with a solution of mercury bichloride, i to 5000. The pre- 
liminary steps leading up to the removal of the tegmen are 
those of the radical mastoid operation described in Chapter 
XXXIII. The abscess is nearly always close to the tegmen 
and easily reached after that bone has been cut away. If it 
is not found at that point, a probe should be introduced be- 
tween the dura mater and the skull and moved about carefully 
in an effort to disclose the locality of the abscess. When 
found, it should be emptied directly through the osseous cortex 
covering it. The removal of sufficient bone at this place is 
far better than incision of the protecting fibrous wall. Only 
when no other route is available should the pus be drawn 
off through this barrier, and then the antiseptic irrigation 
should be immediately used. Sterile gauze is applied as a 
postoperative dressing for the abscess cavity and in other 
respects the same technique is employed as in the mastoid pro- 
cedure. The size of the cavity soon diminishes on account of 
the release of the compressed brain substance which, after 
pressure is removed, resumes its normal place. 

In passing from the consideration of extradural abscesses to 
other intercranial complications we take up a group of diseases 
whose death-rate is appallingly high and which, not many 
years ago, were considered necessarily fatal. At the present 
time prompt operation will save a proportion of patients, but 
the mortality is such as to lay the very strongest emphasis 
upon prophylaxis, upon such energetic treatment of the aural 
diseases as shall prevent their extension to the brain. The 
lateral sinus, either in its horizontal or sigmoid portion, may be 
the seat of a thrombus originating as do other thrombi from 
changes in the structure of the venous walls, but such a throm- 
bus usually begins as a septic clot. It is seldom large enough 
to block up the sinus, and for a considerable time after its for- 
mation it is liable to remain adherent to one side of the sheath, 
causing hardly any local symptoms. After a while morbid 
changes in the sinus wall take place, producing disintegration 



INTRACRANIAL COMPLICATIONS OT EAR DISEASE, 429 

which spreads to the thrombus and it then rapidly degenerates., 
setting free in the circulation multitudes of pyogenic bacteria. 
This occurrence gives rise to marked constitutional symptoms, 
a sudden and severe chill and a rise of temperature to 104 or 
105 F. Then follows a remission, when the temperature 
becomes nearly normal; but in five or six hours there is 
another chill and another high marking of the thermometer/ 
These alternations continue, as horde after horde of hostile 
germs spreads through the body, inducing septicaemia and ex- 
hausting the vital powers. The earlier an operation is per- 
formed the more chance it has of success. Its first step is to 
ligate the jugular vein in the neck; the second is to open the 
sinus through the mastoid, removing enough of the exterior 
wall to gain free access to the thrombus which must be thor- 
oughly scraped away with a dull curette. All diseased tissue 
and all morbid products must be removed, so as to effect com- 
plete evacuation and extirpation of the jugular cavity. A 
thrombus is sometimes formed in the cavernous sinus and in 
this situation is very likely to prove fatal; but there are recorded 
cases where this sinus, so difficult of access, has been emptied 
of its contents and cleansed by the Hartley-Krause operation 
performed in much the same way as for Gasserian extirpation. 

Cerebral abscess is, in a great majority of cases, the result 
of chronic disease of the middle ear. Statistical information 
collected by many observers shows that eighty-five per 
cent, of the cases are due to this cause. The first stage is 
often one of partial latency and may point to a general toxaemia 
rather than to a local lesion. Gradually symptoms of inter- 
cranial pressure appear. There is severe headache, pyrexia 
of intermittent type and vomiting which, unlike that caused 
by gastric diseases, has no relation to the taking of food and 
frequently is without nausea. As the abscess grows, psychic 
symptoms — aphasia, stupor,, delirium and others — supervene. 

Cerebral abscesses occur most frequently in the spheno- 
temporal lobe, and it is a matter of importance to determine an 
area upon the outside of the skull which corresponds with the 



430 NOSE, THROAT AND EAR 

region where the lesion is likely to be found. This area is 
mapped out by Kronlein's landmarks, whose demarcations 
produce several geometrical figures, the one designed for our 
present purpose being a square whose side measures from 
an inch and a quarter to an inch and a half, in proportion to 
various sizes of skulls (Fig. 130). The lower side of this square 
is a segment of a horizontal line, termed "Read's base line," 
extending from the lower margin of the orbit to the occipital 
protuberance. The upper side of the square is a segment of a 
line parallel with "Read's base line," beginning at the supra- 
orbital margin and produced backward. The anterior vertical 
side of the square is made by a perpendicular line produced up- 
ward from the condyle of the lower jaw, and the posterior verti- 
cal side is made by a perpendicular, tangent to the posterior 
margin of the mastoid. This square, called "Von Berg- 
mann's area," covers the region where suppuration usually 
occurs and here the bone should be perforated. Access is 
gained by prolonging the incision through the soft parts made in 
the Stacke-Schwartze operation (see Fig. 131), and turning 
back the flaps. A trephine is then employed to remove a 
circular piece of the squamous portion of the temporal bone, in 
the upper part of the square just described. 

While the collated experience of many surgeons proves 
that the abscess can usually be reached by a perforation within 
Von Bergmann's area, this is not always the case and it is 
so important to discover the best route of access that before 
operating I adopt, whenever possible, a preliminary precau- 
tion. This is to hold consultations with an ophthalmologist 
and a neurologist to ascertain whether either the appearance 
of the eye-ground, or the neural symptoms and reactions, give 
any help in localizing the accumulation of pus. Such consulta- 
tions are not always practicable. The urgency of the situa- 
tion may not allow sufficient time to secure the services of 
the specialists required and there may be other obstacles, which 
one cannot surmount; furthermore, in many instances the 
ocular and neurologic findings add nothing of real value to 



INTRACRANIAL COMPLICATIONS OF EAR DISEASE 43 1 

the indications already known; nevertheless, it is judicious for 
the otologist to seek such cooperation whenever available, and 
to give due weight to any new information it may elicit. 

When the osseous cover of an abscess has been removed by 
trephining, the dura thus exposed is carefully inspected and 
if the membranes are found to be cedematous, congested or 
adherent, we conclude that the diseased area is very near. 
If the dura is lightly touched with the finger and pulsation is 
absent or very feeble, this interruption indicates the close 
proximity of the abscess. Sometimes the patient is in such 
imminent danger, that we are forced to evacuate the pus at 
once, despite the risk of spreading septic inflammation; but 
if the conditions justify a brief delay, the surface of the arach- 
noid is touched with pure, liquid phenol, an occlusive dressing 
of sterile gauze is applied and the head encircled by a retain- 
ing bandage. Eight hours are allowed for the phenol to produce 
its effects. If this application has the result desired, we will 
find at the expiration of the period of delay that the phenol 
has incited a plastic inflammation with exudation of lymph, 
which seals up the sub-arachnoid space and all the interstices 
beneath the dura, thus surrounding the purulent mass with 
a wall which prevents further invasion of the meninges and 
gives the opportunity to remove by evacuation and subsequent 
irrigation the purulent fluid, not only partially, but altogether. 

Whether we have secured this favorable condition, or are 
compelled to open an abscess without inclosing walls of 
lymph, the incision to be made is designed to give the best 
possible outlet to the suppurating mass. We make an ade- 
quate opening through the dura by lifting it with a small 
tenaculum and then with a pair of small scissors make a dural 
flap large enough to permit the thorough inspection of the 
brain substance lying underneath. This flap is turned to one 
side and then an incision into the brain made with a sharp, 
slender scalpel. This instrument is preferable to a trocar and 
canula because its keen edge causes less laceration than a duller 
implement and because a canula, through which pus is flowing 



432 NOSE, THROAT AND EAR 

is liable to be clogged by some particle of solid matter. If 
the knife does not upon its first thrust release the contents of 
the abscess, the blade must be inserted in different directions 
until the outflow of pus shows that the mass has been punc- 
tured. After withdrawing the liquid immediately accessible, 
drainage should be maintained by a double rubber drainage 
tube, secured with a safety-pin outside of the external wound 
to prevent its slipping inward. This tube is also used for irri- 
gation with normal salt solution which should be practiced 
each day. 

A light protective dressing is used over the wound during 
the process of repair by granulation. In every procedure 
connected with brain abscess — preparation, operation and post- 
operative treatment — the strictest asepsis is indispensable. 
Convalescence is slow and supporting constitutional treatment 
may be required throughout its course. 

Cerebellar abscesses, which are about half as numerous 
as those of the cerebrum, are treated in a similar way. The 
area best adapted for perforation with the trephine, to reach 
the usual locality of the lesion, is a circle half an inch in diame- 
ter, inscribed three-eighths of an inch below and behind the 
inferior, posterior corner of Von Bergmann's area (Fig. 130I), 
and the dermal incision and osseous perforation are similar to 
those illustrated in Figs. 130 and 131. 

Meningitis due to aural disease exhibits at the onset the 
same symptoms as when it has a different origin. There is 
the initiatory chill, the high temperature, rapid pulse and 
excruciating pain in the head and neck. When the spinal 
cord is involved there is also the pathognomonic sign of opis- 
thotonos, the bending of the trunk like a bow, while the head 
is strongly retracted. The disease appears in two forms, the 
serous in which the prognosis is rather hopeful, and the puru- 
lent which is almost uniformly fatal. A differential diagnosis 
is often aided by the lumbar puncture, now widely employed 
for this purpose and also as a therapeutic measure. If the 
trunk be encircled by a line touching the crest of the ilium on 



INTRACRANIAL COMPLICATIONS OF EAR DISEASE 



433 



both sides, this line will pass over the spine of the fourth lumbar 
vertebra just below the third lumbar intervertebral space, chosen 
by general consent as the point for puncturing the spinal canal. 
A strong, hollow needle, two inches in length and carefully 
sterilized, is suitable for making the perforation. In health 
the cerebro-spinal fluid escapes through the needle when 




Fig. 130. — Guiding landmarks used in locating brain abscess. Read's base 
line is indicated by the letters AEFB. The square EFI1G is Von Bergman's area. 
/ indicates locality of cerebellar operation. 



its point has entered the canal, drop by drop, but in meningitis 
the intraspinal pressure is so much increased that for some 
seconds there may be a steady stream of the liquid. In 
purulent meningitis pus is always present in the cerebro-spinal 
fluid. If it is very abundant, it may give rise to a cloudy 
28 



434 



NOSE, THROAT AND EAR 



opacity easily recognized; when the quantity is small, the 
microscope will detect pus cells and their presence may also be 
determined by the aid of chemistry. The normal fluid has an 
alkaline reaction, but pus renders it acid; so, too, dextrose which 
is a constituent of the fluid in health is destroyed by the 
suppurative process and its absence can easily be shown by 




Fig. 131. — For a cerebral operation the area of the cortex exposed by the 
Stacke-Schwartze incision, AB, is enlarged by the curved section CD. In case 
of operation upon the cerebellum, the Stacke-Schwartze line EF is prolonged to G. 



the addition of a few drops of Fehling's solution, the well- 
known test for sugar in the urine. If the copper salt in the 
reagent is not reduced by admixture with the fluid under ex- 
amination, pus is present and there is meningeal suppuration. 
The therapeutic value of the lumbar puncture arises from 
reduction of the excessive intracranial pressure by lessening the 
quantity of the cerebro-spinal fluid. The withdrawal of 
several drams often greatly ameliorates the pain, muscular 



INTRACRANIAL COMPLICATIONS OF EAR DISEASE 435 

rigidity or clonic spasms. The effect of the measure upon 
these symptoms is the gauge for its employment. Aside from 
this expedient, the treatment is expectant and aims to relieve 
the patient's suffering and to sustain his vitality, until the 
natural power of resistance may overcome the disease. 



CHAPTER XXXVII 
DEAFNESS AND MUTENESS 

In the sociologic classification adopted by the National 
Conference of Charities and Correction, the Deaf-mutes 
constitute Class 2 of Group C, the Defectives. 1 In countries 
of which we have statistics their number varies from 1 in 
3000 to 1 in 500 of the whole population. Their education 
during school years and their subsequent occupational status 
are important factors in the complex social problem which 
confronts civilized society. 

The majority of mutes are found among those who are 
congenitally deaf or have become deaf in early infancy. 
When at a later period disease or traumatism causes aphonia 
or aphasia, these defects are rarely accompanied by deafness 
and, when it is present, its relation to them is not causal. It 
must be remembered that, as used in this connection, the word 
"mute" refers not to absence of voice but to want of articulate 
speech whose physiology is quite different from that of phona- 
tion, as was pointed out in Chapter XXI. The normal child 
emerges from infancy (in + fans = not + speaking) and learns 
to talk by imitating the utterances of other persons, especially 
other children. Hearing a word, he tries to repeat it and, after 
many trials and failures, learns the movements of the articulat- 
ing organs, which will produce that word, the process being 
entirely one of imitation and experiment. The child, born deaf 
or becoming so soon after birth, has nothing to imitate and is 
wholly excluded from instruction by this method. To express 

1 The other classes of Defectives are: 1. the Blind; 3. Insane; 4. Idiots (feeble- 
minded); 5. Epileptics and 6. Inebriates. The last two classes comprise only 
advanced cases, in which epilepsy and inebriety have gone far enough to destroy 
efficiency. 

436 



DEAFNESS AND MUTENESS 437 

his desires and give vent to his emotions he must have 're- 
course to pantomine (the primal sign-language) and to nearly 
instinctive, animal noises, such as cries, screams, howls and 
moans, sounds whose signification is readily interpreted but 
have a very narrow range of meaning. Unless the child receives 
special instruction, he does not go much beyond this and in 
adult life remains a mute, not because his organs of voice 
and speech have any anatomical abnormality, but simply 
because he has never learned to use them for the utterance of 
words. Children who have acquired speech and subsequently 
lost their hearing, do not lapse into mutism. They continue 
to speak in a comprehensible way, but the finer modulations of 
tone and articulation may be lost because they no longer possess 
a standard with which to compare their utterances. These 
facts regarding speech and the lack of it appear commonplace, 
but they are exceedingly important and it was the neglect 
to properly comprehend and apply them that for generations 
prevented progress in methods to instruct deaf-mutes in a 
way which would rehabilitate them and take them out of the 
category of "incapacitated defectives." 

The first long step taken in the education of mutes was 
the invention of the manual alphabets, single and double 
handed, by which words are spelled in a visible way. This 
device is a specialization of the primitive sign language, but by 
utilizing the idea of the written alphabet, it so broadens the 
scope as to include all words in languages having quasi phonetic 
letters. It cannot be used with an ideographic language like 
the Chinese. In the two-hand alphabet the signs bear a 
resemblance to the shape of our printed (Latin) characters, 
hence they are very easily remembered and were learned by 
many normal children, who were thus able to communicate with 
mutes and also employed the signs for silent conversations 
with each other, actuated by that love for secrecy and mystery, 
which is such a strong motive in adolescence. The bimanual 
alphabet was, however, a slow and cumbersome instrument of 
communication and was before long superseded by the one- 



438 NOSE, THROAT AND EAR 

hand alphabet, which greatly increased the speed possible of 
attainment. By using abbreviations and conventional forms of 
motion, the rate at which thought may be accurately commu- 
nicated by expert users of the single-handed alphabet has been 
developed to an astonishing rapidity. The development of 
this speed has conferred upon well-trained mutes the capacity 
for dialogue and also for lecturing before a class or other small 
audience, in a way that is quite free from the former discourag- 
ing tediousness. 

This great advantage has been gained at a heavy cost in 
another direction. Not many persons, except mutes them- 
selves, understand the one-hand alphabet, which is far harder 
to learn than the bimanual one, with its imitative features. 
Very few indeed ever devote the time and effort to become ex- 
pert in its use, hence the rapid hand movements of mutes 
conversing with each other are wholly incomprehensible to 
nearly all speaking people and the barrier between them is 
more impassible than if the mutes had never been educated and 
were forced to depend upon the primitive sign language and the 
animal noises which, however narrow their range, were quite 
well understood by everybody within those limits. It thus 
came to pass that the work of the great institutional schools 
for the deaf and dumb, upon which millions of dollars had 
been expended, had a tendency to segregate their pupils from 
the rest of the community and to render communication be- 
tween them and speaking people difficult and hence infrequent. 
The philanthropic men, who had devoted themselves to the 
good of this class of defectives, were confronted by a serious 
economic question: how can the mutes trained in the sign- 
language schools find remunerative employment? Much the 
larger part of the rising generation in every land must secure a 
livelihood by earning it and among mutes the proportion 
subject to this necessity is even greater than the ratio for the 
community at large. How shall these young people, handi- 
capped by lack of speech, find work amid the competitive con- 
ditions everywhere prevalent? One answer to this question 



DEAFNESS AND MUTENESS 439 

was that the State should transfer the mutes, upon the com- 
pletion of their school course, to industrial colonies where they 
should engage in agriculture and manufacturing of various 
sorts, creating self-supporting communities, where the sign- 
language would be the lingua franca and where the citizens 
would be free from the unfair competition of people possess- 
ing all the special senses. If this plan had been adopted it 
might have led to the production of a wholly deaf variety of 
the human species, for by the intermarriage of the colonists 
the defect would have been transmitted to the next generation 
and continued in-breeding would have tended to make it 
permanent and universal. In addition to inflicting this dis- 
ability upon posterity the colonial scheme would have worked 
great injury to the present generation. Such segregation of 
mutes would have been contrary to the well-recognized sociologic 
law that " Association based upon a defect is injurious." This 
is true even if the defect is merely somatic and has apparently 
no psychic influence. If a community was founded by persons 
who had each suffered the amputation of an arm, it might at 
first show certain advantageous results due to the invention 
of industrial methods which could be pursued by one-armed 
men, but ultimately there would be mental and social deteriora- 
tion whose only cure would consist in changing the character 
of the community by an influx of people who had suffered no 
mutilation. The project of colonizing the mutes was aban- 
doned in favor of a more rational scheme which constituted 
the second great advance in dealing with the subject. 

This scheme was the introduction of oral teaching, either 
side by side with the manual sign language, or as a substitute for 
it. Instruction by this method enables the mute child to ac- 
quire speech by watching the movements of the lips and the 
facial muscles of the teacher who of course makes the motions 
in a peculiarly deliberate and uniform way. The speech 
which the pupil acquires is of a poor kind, harsh, inaccurate 
and often of disagreeable intonation, but it is real speech, 
expressive of ideas and comprehensible to persons with normal 



44-0 NOSE, THROAT AXD EAR 

hearing. In these respects it has immense superiority over the 
other methods of communication, for it abolishes the segrega- 
tion of the deaf-mutes and restores them to a place in the 
general community. It is far better for them and for their 
progeny that they should take part in the general communal 
life than seek temporary advantage in segregation, at the 
cost of deterioration for themselves and their posterity. Com- 
petition with normal workers remains a hindrance, but its 
effect is greatly diminished by oral training, for the com- 
paratively small vocabulary used in any industry is soon ac- 
quired by the deaf worker and his practice before long enables 
him to speak this list of words quite well, so that during working 
hours his defect is almost in abeyance and his chances of 
success are fairly good. This is proved by the fact that very 
few of the lip-reading deaf are found among the destitute 
classes. 

Recently a third advance has been made and one which has 
peculiar interest for members of the medical profession, for its 
success and the realization of the hopes of its promoters, de- 
pend very largely upon cooperation among those most closely 
connected with the rehabilitation of deaf-mutes and their 
restoration to social responsibilities, labors and enjoyments. 
These are the instructor whose viewpoint is pedagogical, the 
physician who approaches the subject from the side of aural 
therapeutics, and the publicist who considers its bearings upon 
public expenditure, industrial productiveness and the other 
interests of the Commonwealth. The present trend of thought 
results partly from the agitation in favor of the oral plan of 
teaching. It was advocated as a means of imparting the use 
of spoken words by watching the action of the labial and 
other muscles, when surdity has made the natural method 
of acquiring the words impossible and, although the imita- 
tion of normal speech which it gave was very imperfect- 
yet for some purposes it was better than the manual substitute. 
The current movement aims to come still closer to the natural 
function by conserving and utilizing whatever fractions of 



DEAFNESS AND MUTENESS 441 

auditory power may exist, due either to the presence of a small 
part of the auditory mechanism, produced in foetal life, before 
the arrest of development, or to remnants of this mechanism 
which escaped the ravages of disease that destroyed all the 
rest. In many so-called "deaf-mutes," domiciled in the in- 
stitutional schools, the existence of such auditory fractions was 
for a long time almost wholly ignored. 1 We now know that, 

1 The unfortunate condition formerly prevailing in some schools for mutes, by 
which the pupils derived no benefit from the progress of otologic medicine and 
surgery, is shown by the following case, occurring nearly twenty years ago. A 
lad of eight was admitted to a State school for mutes, was given a uniform and a 
number and put under instruction, but subjected to no aural examination. 
Some months afterward he contracted broncho-pneumonia and, on account of 
the absence of the school physician, was attended by Dr. B., a practitioner of 
the neighborhood who was convinced by various incidents that the boy was not 
entirely deaf. Dr. B. asked permission to take the lad, during convalescence, to 
an otologist, but was refused by the principal with the curt remark, "If No. 
144 were not deaf and dumb, he would not be here." Dr. B. though rebuffed 
was not discouraged. After recovery the boy was allowed to pay a visit to his 
parents and they were asked for the permission which had been denied. They 
were poor people of a neighboring village and could incur no expense, but when 
Dr. B. promised there would be no charge, they gladly agreed to his proposal. 
The otologist became much interested and aided in securing the case history, 
which was substantially, as follows: In early infancy, there was "a running 
from both ears" which ceased after a time, but left the child deaf. He never 
learned to speak and when eight years old was pronounced a mute by the 
village doctor who filled out the application papers for the training school. At 
no time were the ears treated by a specialist. Examination disclosed no disease 
of the labyrinth and the mastoid seemed to be normal, but the right tympanum 
was closely packed with a partly organized mass, somewhat resembling a choles- 
teatoma, though with many differences. The left tympanum was in a similar 
condition, except that here the mass appeared to be dessicated and had shrunken 
on the anterior side, leaving a narrow passageway through which some atmos- 
pheric vibrations were transmitted to the tympano-labyrinthine partition. In 
this ear there was some audition; Dr. B. had not erred in his opinion. The 
mass in the right ear cut off all conduction, but when both tympani had been 
thoroughly cleansed, this was found to be the better ear, for its ossicles were 
but slightly damaged, while on the other side they were carious and the hearing 
in the left ear was only a little improved by removal of the obstructing mass. 
Considerable auditory power was recovered upon the right side and the boy 
signified its presence and his consequent delight by signs, for of course he was still 
mute. His parents wished him to remain at the school, where he was supported 
free of cost to them, and in spite of his recovered hearing he was trained just as the 
other pupils, the principal making it plain that he was ill pleased by the otol 



442 NOSE, THROAT AND EAR 

even when a part of the labyrinth is congenitally lacking, 
there may be "islands of hearing" which can perform ser- 
vice under proper management and if the defect is in the 
middle ear, rather than the internal, there is a still better 
chance of securing some functional action. This modicum of 
real hearing has a twofold value: it has worth as a means of 
communicating ideas, a value which can be measured by an 
equal power possessed by a substitute, such as lip reading, or 
the manual alphabet, and in this respect its utility can be 
accurately determined, as neither greater nor less than that of 
the other medium of transmission. Beside and beyond this 
value there is another which is strictly sui generis and outside 
the range of any substitute. This is the psychic influence of 
audition exerted upon the imagination and the emotions. 
The subject has as yet received little study, but enough to 
make it sure that the loss of this influence which can proceed 
from nothing but audition has a permanent and injurious 
psychologic effect. There is today general agreement that what- 
ever hearing remains in one nearly deaf should be carefully 
conserved and fostered. 

As yet, practical measures are not abreast of theoretical 
opinion. The specialist on ear diseases, whose name appears 
in the annual report of a deaf-mute school, is still in many 
instances an occasional visitor who receives no salary and 
gives to the institution just what time he can spare, actuated by 
his interest in otology and his sympathy for the children. The 
pupils should be under constant medical supervision and, 
to secure this, the name of the otologist must be on the perma- 
nent pay-roll and his services placed upon a business basis. The 
expense incident to such medical supervision will generally fall 
upon the public treasury and this implies awakened interest 
and intelligent cooperation on the part of the fiscal officers of 



interference, but the little fellow taught himself to speak and was dubbed by his 
companions, "the gabble mute." Later he secured employment with a produce 
dealer and, though hard of hearing, was able to hold his own among normal boys. 
He now occupies the responsible post of head bookkeeper in a business house. 



DEAFNESS AND MUTENESS 443 

the State. This is not far off. The publicist of the future 
(at least in our country) must and will take an interest in the 
defective classes and do his part to restore to normal condi- 
tions of life those who, through no fault of their own, are now 
segregated in an isolated group and thus deprived of that 
equality of opportunity which America wishes to secure for 
every citizen. Only by the intelligent co-working of educator, 
otologist and publicist, can we hope to attain the ideal status 
of the class of deaf defectives, when their number will be re- 
duced to a minimum and when the few who remain in the 
class will hold a useful, independent and honorable place in 
the community, contributing to its prosperity fully as much 
as they derive from its resources. 



INDEX 



Ablation of malleus, 274 

of tissues in nosogenic region, 116 
Abscesses in auricle, 328 

in skin of nose, 69 

intranasal, 69 

pointing toward larynx, 209 
Accessory organs, 3, 4 
Accumulated serum from obstructed 

tubes, 347 
Aconite in acute pharyngitis, 194 
Acute catarrhal pharyngitis, 192 

tonsillitis, 208 
Adenoids, 177 

as cause of tubal obstruction, 345 
Advantages of Mosher's operation, 140 
Air bag, 26 

comminutor, 23 

compressed, 20 
gauge, 22 

pressure affecting pharynx, 191 
Alcohol, 31 

in laryngeal papillomata, 273 
Amblyopia in sphenoidal sinusitis, 143 
Ammonia, 31 

Ammonium chloride in chronic laryn- 
gitis, 252 
Amputation of uvula, 100 
Anaesthesia in removing extranea, 73 

of larynx, 283 

vapor, 22 
Anatomical basis of Mosher's opera- 
tion, 138 

variations in uvula, 198 
Anatomy of mastoid region, 380 

of tympanum, 296 
Anomalies in nasal sinuses, 112 
Anterior plugging in epistaxis, 165 



Antipyretic treatment of, mastoiditis, 

384 
Antitoxin in diphtheria, 103 
Antrum of Highmore, 120 

of the mastoid, 381 
Anvil or incus, 297 
Appendices in the auricle, 327 
Arguments for tonsillectomy, 220 
Aristol, 35, 109 
Armamenta, 14 

Arrangements for tonsillectomy, 219 
Artificial lights, 18 

Artistic requirements in nasal restora- 
tion, 151 
Asch-Douglass operation, 46 
Asch forceps, 55 
Aspirator, 23 
Asymmetrical septum, 43 
Atomizer, 23 

Atresia of auditory meatus, 326 
Atrophic form of chronic laryngitis, 

253 

nasopharyngitis, 175 

rhinitis, 93 
Atrophy of adenoid tissues, 177 
Auditory labyrinth, 406 
Aural examinations, 306 
Auricle or external ear, 292 
Auscultation tube, 26 
Automatic air compressor, 20 
Autumnal catarrh, 95 



B 



Bacillus foetidus, 94 
of influenza, 99 
Barany's discovery of past-pointing, 

419 
Battery, storage, 20 



445 



446 



Benign tumors of naso-pharynx, 189 
Bezold's mastoiditis, 392 

views on otosclerosis, 403 
Bimanual alphabet for mutes, 437 

operation on uvula, 202 
Bismuth subnitrate, 35 
Blake's table of phonetic intensities, 

322 
Bleeding from the nose, 161 
Blindness caused by frontal sinusitis, 

133 
Blood pressure test, 30 
Bosworth's nasal specula, 24 
Boulton's solution, 87, 174 
Boundaries of surgery and medicine, 

235 
Bracket lamp, 19 
Brandegee forceps, 185 
Brandy, 31 
Breath-road, 2, 4 

and food-road coincident, 168 



Cabinet for instruments, 16 
Caldwell-Luc operation, 125 
Caleidic surgery, 145 

treatment of the ear, 326 
Calomel, 35 

Caloric test, nystagmus, 410 
Camphor, 35, 87 
Carbolic acid, 34, 358 
Carcinoma of nose, 70 
Cartilage of septum preserved, 54 
Cartilages of larynx, 236 
Catabasis of cells, 91 
Causation of the running ear, 366 
Cauterization with chemicals, 80 
Cerebellar abscess, 432 
Ceruminous accumulations, 331 
Chair for patient, 15 
Chalk deposits in drum-head, 379 
Children very subject to simple otitis 

media, 351 
Chloride of epinephrin, 32 
Chloroform in night croup, 248 
Cholesteatomata in tympanum, 369 



Chromic acid, 33, 57, 86, 372 
Chronic laryngitis, two forms, 250 

otitis media, 359 

pharyngitis, 195 

rhinitis, 82 

tonsillitis, 216 

uvulitis, 100 
Classification of defectives, 436 
Cleft palate, 198 
Clergyman's sore throat, 196 
Cocaine hydrochlorate, 36 
Cochlea, 100 
Cold bathing a cause of otitis media, 

353 
favors attacks of rhinitis, 78 
wire snare, 65, 85, 190 
in tonsillectomy, 225 
to remove aural polypi, 372 
Colonization of mutes abandoned, 439 
Columnar cartilage deflected, 56 
Comminutor for air, 23 
Complexity of hearing, 289 
Complications of chronic nasopharyn- 
gitis, 176 
Compressed air, 20 

Concealing post-operative disfigure- 
ments, 399 
Concepts derived from few sensations, 

T 55 
Conjunctivitis following rhinitis, 159 
Consequences of adenoids, 178 
Consumption of the throat, 255 
Constitutional treatment in laryngeal 

phthisis, 258 
in simple otitis media, 357 
Contagion of diphtheria, 103 
Cooperation with dentists, 123 

with nerve and eye specialists, 430 
Corrosive chemicals causing rhinitis, 

7S 
Cosmetic surgery, 145 
Counter-irritation, 77 
Croup, night or spasmodic, 247 
Crypts cleansed and cauterized, 211 
Cure of adenoids illustrated, 181 
Curette in treating polypi, 66 
Cuspidor for office, 17 



INDEX 



447 



Danger from electrocautery, 84 

from fused silver nitrate, 34 

in epistaxis, 163 

in neglecting perichondritis, 336 

in tonsillar diseases, 206 

of pushing extranea downward, 
280 
Dangers in septal operations, 43 

to sight in sphenoidal sinusitis, 
141 
Deafness and muteness, 436 
Deformities and diseases of auricle, 
326 

of nasal septum, 44 
Delstanche's masseur, 27, 310 
Dench's whistle, 28 
Dental origin of sinusitis, 123 
Department of neuro-otology, 419 
Destruction of tubercular sputum, 260 
Details of Yankauer's operation, 89 
Development and atrophy of faucial 
tonsils, 204 

of lingual tonsil, 231 

of otology, recent, 288 
Deviation of nasal septum, 40, 44 
Diagnosis, analytical, 7 

of adenoids, 182 

of cholesteatoma ta, 370 

of epistaxis, 163 

of frontal sinusitis, 130 

of nasal tuberculosis, 109 

of nasopharyngeal growths, 188 

of syphilis, 106 

synthetical, 8 
Diagnostic error, 6 
Differences in olfactory power, 154 
Different media of vibration, 303 

qualities of male and female 
voices, 242 
Differential diagnosis of diphtheria, 

215 
Difficulties in study of labyrinth, 406 
Diphtheria, 102, 103, 212 
Diphtheritic laryngitis, 264 
odor, 102 



Disappointment in plastic operations, 

Discoloration of nose, 145 

Diseases intercurrent with purulent 
otitis, 366 
of internal ear, 406 

Disfigurement of nose, 144 

Distention of lachrymo-nasal duct, 88 

Distressing tinnitus in otosclerosis, 402 

Disturbed equilibrium sign of mastoid 
lesion, 378 

Divisions of the pharynx, 168 

Dobell's solution, 34, 86, 174, 194, 
246, 357 

Dog's voice a single exception, 243 

Dover's powder, 194, 246 

Drum-head, 295 

Dual significance of vestibular symp- 
toms, 408 

Dunbar's serum for hay fever, 96 

Dysphonia clericorum, 196 



Ear, form and function, 288 
rings and ear-drops, 328 

Eczema of auricle, 333 
of nose, 147 

Education of the special senses, 154 

Electrocautery, 20, no 

Elevator of Dr. Potts, 50 

Eliminative treatment in chronic 
otitis media, 361 

Embarrassment in treating disfigure- 
ments, 144 

Embolism following injections of 
paraffin, 150 

Emergencies, 14 

Emetics in night croup, 248 

Endolymph, 301 

1 olargement of surgical field, 235 

I I'iiM phrin chloride, 32 

Epiphora, 87 

Epistaxis, 161 

Equality of opportunity for mutes, 443 

Equiqment, 1 1 

Erectile tissue of septum, 57 



448 



INDEX 



Errors in computing power of hearing, 

3*9 
Erysipelas of auricle, 340 
Escape of pus through mastoid cortex, 

283 
Estimation of perception of sound, 

316 
Ethmoidal abscess pointing to orbit, 
120 
sinus, 113 
Ethmo-turbinate knives, 116 
Etiological questions, 9 
Etiology of chronic pharyngitis, 195 
of laryngeal phthisis, 256 
of laryngitis, 244 
of otosclerosis, 401 
of polypi, 63 

of simple otitis media, 350 
of tubal obstructions, 345 
Eustachian catheter, 313 

dilatation in chronic otitis, 363 
tube, 298 
Evils of segregating mutes, 439 
Exciting cause of epistaxis, 162 
Exemplification of past-pointing, 423 
Explosive noises injurious to ear, 417 
External auditory meatus, 294 
ear lesions, 326 

operation for cholesteatoma, 372 
on frontal sinus, 133 
Extirpation of laryngeal neoplasms, 
274, 276 
of lingual tonsil, 233 
of nasopharyngeal tumors, 189 
Extraction of foreign bodies from nose, 

73 
Extradural abscess, causation and 

course, 426 
Extranea impacted, 71 
motile, 71 



Facial paralysis indicating mastoid 

disease, 378 
False membrane on tonsils, 214 
vocal cords, 238 



Fatalities in voluntary destruction of 
hearing, 342 

Fatality in disease of inner ear, 407 

Faucial tonsils, 204 

Faulty metabolism causing pharyn- 
gitis, 193 

Feeding children after intubation, 27.1 

Fibromata in nasopharynx, 189 
intranasal, 67 

Fistula auris, 327 

Five stages of Hinsberg operation, 

415 

Flap operation on nasal septum, 45 

for perforation, 59 
Follicular tonsillitis, 210 
Food-road, 2, 4 
Forceps in treating polypi, 66 

which neither slip nor tear, 223 
Foreign bodies in larynx, 279 

in nose, 71 

in the auricle and auditory mea- 
tus, 320 
Forms of nystagmus, 410 
Fourfold procedure in treating sinuses, 

115 
Freeman's sinus probes, 131 
Frequency of simple otitis media in 

children, 351 
Frontal sinus, 128 
Furuncles of skin of nose, 69 
Furunculosis of auricle, 335 



Galton whistle, 28, 323 

Galvanic current in hyperplasia, 327 

reaction, nystagmus, 410 
Galvanocautery in laryngeal phthisis, 
260 

in nasal tuberculosis, no 
Gardiner-Brown test of hearing, 324 
Gauge for air pressure, 22 
General plan of treating sinuses, 114 

sensation auxiliary to hearing, 261 
Germ nidus in faucial tonsils, 207 
Gift of voice very limited, 242 
Glands of the nasopharynx, 169 



INDEX 



449 



Glottis, oedema of, 249 

smallest part of breath-road, 239 
Gothic arch, 40, 179 
Great frequency of middle ear diseases, 
344 

intraspinal pressure in meningitis, 

433 
Grippe, 99 
Gruber's method of inflation, 312 

speculum for external meatus, 
309 
Guaiacol, 33 

Guarded prognosis in mastoiditis, 383 
Gummata causing disfigurement, 107 



H 



Hematoma, nasal, 67 

Haemophilia preventing septal opera- 
tions, 43 

Haemorrage after tonsillotomy, 218 
arrest of, 32 

Haemostasis in tonsillectomy, 226 

Hajek's posterior group of cells, 113 

Hand pump, 22 

Hardened ear-wax, impairing hearing, 
332 

Hard rubber atomizer, 23 

Hartley-Krause operation, 429 

Hartmann's cutting forceps, 373 

Hay fever, 95 

Head band, 19 
mirror, 19 

Hearing destroyed to avoid conscrip- 
tion, 342 
has greater range than sight, 305 

Helen Keller's education, 291 

Herpes of the auricle, 326 

Hewitt's apparatus for spraying middle 
ear, 371 

Hinsberg operation, 414 

Hodson's head-light for use in tonsil- 
lectomy, 222 

How children learn speech, 436 

Hurd bone-cutting forceps, 55 

Hydrogen peroxide, 34, 94, 371 
sprayed on tonsils, 109 



Hygienic treatment in laryngeal 

phthisis, 258 
Hyperasmia, 77 
Hyperaesthesia of larynx, 284 
Hypertrophic rhinitis, 83 
Hypertrophies of lower turbinal, 90 

producing tubal obstruction, 346 
Hypodermic injections, 30 



Ice-bag cravat, 209 

Illustration drawn from rotation test, 

412 
Implement of preference in opening 

antrum, 389 
Impure tones of ticking watch, 321 
Inaccessibility of mastoid cells, 384 
Incision of drum-head, 367 
Incus, removal of, 375 
Infections, nasal, 99 
Infectious disease of larynx, 255 

fevers cause of otitis media, 351 
Inflammation, etiology, 75 
Inflation of tympanum, 311, 358 
Influenza, 99 
Ingals nasal specula, 24 
Injuries of ear by machinery, 329 
Injury of hearing by tubal obstruction, 

347 
Insects in nose, 73 

lodged in ear, 330 
Insidious course of mastoid disease, 

385 
Inspection of ear, 308 

of mastoid region, 310 
Instrument cabinet, 16 
Instrumental aids supplant natural 

powers, 156 
Instruments for operation on the 

mastoid, 386 
for ossiculectomy, 376 
for radical mastoid operation, 

395 
Insufflator, 23 
Intermittent phonation due to pedun 

1 ulated tun* 1 



45° 



INDEX 



Internal ear, 299 
diseases, 406 
Intracranial complications of ear dis- 
ease, 425 
Intranasal operation on frontal sinus, 

131 
Intubation in diphtheria, 265 
Involvement of mastoid cells, 377 
Iodide of potassium in syphilis, 108 
Iodine in atrophic laryngitis, 254 
rhinitis, 94 

in nasal hypertrophies, 91 

in nasopharyngitis, 174 
Iodoform, 35 

Iron chloride, tincture of, 33 
Ischaemia, 32 
I. X. L. compressor of air, 21 



Jackson's self -lighted tube, 275 
Japanese napkins, 17 
Joint use of nystagmus, past-pointing 
and vertigo, 424 



Laryngeal cartilages, 226 

extranea, 279 

infections, 255 

neuroses, 283 

new growths, 272 

tuberculosis, 255 
Laryngitis, 244 
Laryngology, 1 
Laryngoscope, 25 
Larynx, form and function, 235 

resembles a reed instrument, 241 
Leptothrix bucalis, 211 
Liberating pus under the dura mater, 

43i 
Ligatures in haemorrhage, 18 
Lights for office, 18 
Limitations of submucous resection, 56 
Limits of pitch recognized by the ear, 

3°5 

Lingual tonsil, 231 

Location in space of semicircular 
canals, 409 

Lowered vitality resulting from ade- 
noids, 179 

Lucae probe applied to drum-head, 363 

Lumbar puncture in meningitis, 432 



Keen smell of the African Bushman, 

155 

Kidney disease from chromic acid, 

75 
Killian's operation, 134 

suspension laryngoscopy, 277 
Kronlein's landmarks, 430 



Labyrinth, 100 

Labyrinthine disease with otitis media, 

360 
Labyrinthitis, 307 
Lachrymo-nasal duct inflamed, 87 
distended, 88 
sac, suppuration, 87 
Lactic acid in nasal tuberculosis, no 
Lacunar tonsillitis, 210 
Largest faucial tonsils on record, 204 



M 



Mackenzie condenser, 19 
forceps, 24 

Maggots and their ova complicating 
otitis media, 331 

Malformations of the nasal septum, 39 

Malignant disease of nose, 70 
growths on external ear, 341 
nasopharyngeal growths, 190 
neoplasms of larynx, 278 

Malleus or mallet, 297 
how removed, 374 

Malnutrition of brain caused by ade- 
noids, 180 

Malpositions of the nasal septum, 39 

Manual alphabets for mutes, 437 

Massacer of the tonsils, 220 

Massage of ear-drum, 28 

Masseur, Delstanche, 27 



45i 



Mastoid cavities converted into one, 
39i 
cells are pneumatic, 381 
Mastoiditis, 380 
Mathieu tonsillotome, 227 
Maxillary sinus, 1 20 
Meaning of the word, hearing, 2 go 
Mechanical test, nystagmus, 410 
Medicated vapors in chronic otitis 

media, 362 
Medicinal treatment in oedema of 
glottis, 249 
in tubal obstruction, 348 
of rhinitis, 86 
Meningitis, serous and purulent, 432 
Mental dullness caused by adenoids, 

180 
Menthol, 35, 87 

Mercurialization in syphilis, 108 
Mercurial vapor in diphtheria, 264 
Mercury and iodine in syphilitic 

laryngitis, 263 
Metastasis, 77 
Mial's saw, 42 

Microbes causing Vincent's angina, 
211 
in pus from tympanum, 365 
Middle ear, 295 

tubal obstruction, 344 
Mild constitutional symptoms in 

mastoiditis, 382 
Mirrored images laterally reversed, 274 
Mirror, head, 19 

toilet, 17 
Mistaken treatment of nasal extrana, 

7i 
Mistakes as to defective children, 182 

regarding high feeding, 259 
Morbid anatomy of chronic naso- 
pharyngitis, 172 
of hyperkeratosis, 212 
proliferation of cells, 368 
tissue removed as a mass, 118 
Mosher's operation, 137 
Motor neuroses of larynx, 285 
Mountains and ocean free from hay 
fever, 96 



Mouth breathing, 37 

due to adenoids, 179 

Mucosa sicca of serious import, 193 

Mucous patches in the larynx, 262 

Muco-purulent nasal discharge in 
boys, 82 

Mutes separated from others by man- 
ual signs, 438 

Mycosis leptothrica, 211 

Myringotomy to evacuate tympanum, 
367 

Myxomatous degeneration, 63 



N 



Nasal carcinoma, 70 

disfigurements, 144 

douche, 24 

responsible for otitis media, 354 

extranea, 71 

fibromata, 67 

ha;matomata, 67 

infections, 99 

neoplasms, 62 

origin of ophthalmic lesions, 158 

polypi, 62 

relations to special senses, 153 

sarcomata, 70 

septum, 37 

sinuses, in 

specula, 24 
Nasopharyngeal neoplasms, 188 
Nasopharyngitis, chronic, 1 7 1 
Naso-pharynx, 168 
Nature of nystagmus, 409 
Need for ossiculectomy, 373 

of medical supervision for mutes, 
442 
Neosalvarsan, 262 
Nephritis intercurrent with tonsillitis, 

208 
Neumann's theory of equilibrium, 417 
Neuroses of larynx, 283 
Neurotic results from disfigurements, 

' 1 1 
New growths in larynx, 272 
Night croup, 247 



452 



INDEX 



Nitrate of silver, 33 

Noguchi reaction for syphilis, 105 

Noses discolored by drunkenness, 

Nosogenic region of the nose, 113 

Novocain, 36 

Nystagmus, 409 







Otology, 1 

Otomycosis, 339 

Otosclerosis, 400 

Otoscope, Siegle's, 27 

Overtones, 241 

Oxide of mercury in septal perforation, 

58 
Ozama, 93 



Obliteration of fistula auris, 328 

of tonsillar crypts, 216 
Obstacles to correct tests of hearing, 320 
Occupational cause of pharyngitis, 196 

rhinitis, 78 
Occupations causing disease of internal 
ear, 416 

influencing septal disease, 41 
Oculists and aurists, 288 
Odor in ozaena, 93 
O'Dwyer's intubation tubes, 266 
(Edematous laryngitis, 249 
Office cabinet, 1 7 

table, 16 
Ogston-Luc operation, 133 
Olfaction damaged by disease, 157 

in the lower animals, 153 

supplements sense of taste, 157 
Olfactory nerve, 153 
One hand alphabet, 438 

operation on uvula, 101 
Onodi on epiphora, 88 
Onset of otosclerosis insidious, 401 
Operation of adenoidectomy, 185 

upon nosogenic region, 117 

upon sphenoidal sinus, 142 
Optic nerve traversing sphenoidal 

sinus, 141 
Oral teaching of mutes, 439 
Organ of Corti, 301 
Orifices of the naso-pharynx, 169 
Ossicles of the middle ear, 297 
Ossiculectomy, 374 
Othaematomata, 337 
Otitis externa crouposa, 339 

diffusa, 338 

media extending from throat, 352 
simple acute and chronic, 350 



Packing in haemorrhage, 32 

with gauze in epistaxis, 164 
Palliative treatment in hay fever, 97 

of lingual tonsil, 233 
Palpation in aural examination, 308 
Papillomata of larynx, 272 
Paracusis Willisiana, 359 
Paraffin in nasal surgery, 148 
Patient's chair, 15 
Past-pointing, 419 

Perforation of drum-head after otitis, 
378 

of septum, 57 
Perichondritis of auricle, 336 
Peril of delaying tracheotomy, 250 
Perilymph, 301 
Periodicity of hay fever, 95 
Peroxide of hydrogen, 34, 94, 371 
Phenol applied to arachnoid mem- 
brane, 431 
Pharyngitis, 191 
Pharyngology, 1 
Physical signs of laryngeal phthisis, 

257 
Plastic art in caleidic surgery, 152 

operations on nose, 147 
Pleas for retention of faucial tonsils, 

205 
Pleasurable sensations promote diges- 
tion, 157 
Politzer air bag, 26 

method of inflation, 312 

test of hearing, 325 
Pollantine, remedy for hay fever, 97 
Polypi as cause of other maladies, 6s 

as result of other diseases, 63 



453 



Polypi in larynx, 272 
in middle ear, 372 
in nasopharynx, 188 
of the nose, 62 
symptoms, 64 
treatment, 64, 65 
Posterior plugging in epistaxis, 165 
Postnasal catarrh, 171 
Potassium permanganate in atrophic 

rhinitis, 94 
Predisposing causes of epistaxis, 161 

of pharyngitis, 192 
Preservation of septal cartilage, 54 
Pressure symptoms in cerebral abscess, 

429 
Primary laryngeal phthisis, 255 
Procrastinating germs of diphtheria, 

103 
Production of the voice, 140 
Prognosis of chronic otitis media, 361 

of inner ear inflammations, 414 
Projection of front teeth caused by 

adenoids, 179 
Protection of nasal duct and lachrymal 
canal, 127 
of raw surface left by uvula ampu- 
tation, 103 
Pseudo membrane in diphtheria, 102 
Psychic phenomena of olfaction, 154 

value of audible speech, 442 
Pus lacking in otitis externa, 338 

present in middle ear sometime 
in nearly all, 365 



Quality in auditory tests, 317 
Quantity in auditory tests, 317 
Quinsy, 209 



Radical mastoid operation, 393 

Randall tuning forks, 29 

Rarefaction of air a cause of epistaxis, 

161 
Rarity of otosclerosis in America, 405 
Read's base line, 430 



Recent advances in education of 

mutes, 440 * 
Reciprocal causation of rhinitis, 75 
Recurrence of night croup, 248 

of polypi, 67 
Regions exempt from hay fever, 96 

of the trunk, 2 
Removal of foreign bodies from larynx, 
281 
of impacted cerumen, 332 
of tampons after epistaxis, 167 
of vomer, 55 
Remnant of hearing after radical mas- 
toid operation, 398 
Repair after radical mastoid operation, 

396 
Requirements for tonsillectomy, 220 
Researches of Dr. Jones, 422 
Resection of attic, 377 
Resonator to measure hearing power, 

3i7 
Resonators of Bezold and Edelmann, 

323 

Restoration of external auditory canal, 
397 

Retained nasal tampons inciting otitis, 
352 

Reversal, lateral, of images in mirrors, 
274 

Rhinitis, 75 
aborted, 80 
atrophic, 93 
symptoms, 79 

Rhinoliths, 74 

Rhinology, 1 

Ribbon operation for septal perfora- 
tion, 59 

Ridges and spurs on septum, 44 

Ring-shaped curette to dislodge chol- 
esteatoma, 371 

RinnS's test of hearing, 323 

Rotation test, nystagmus, 410 

Route followed by vibrations, 302 

S 
Safeguarding edge of mastoid 

390 



454 



INDEX 



Salicylic acid a remedy for otomycosis, 

34° 
Salversan, 108, 262 
Sand blast causing rhinitis, 78 
Sarcoma of nose, 70 
Scarification of glottis for oedema, 

249 
Scars following syphilitic ulcers, 363 

upon the nose, 146 
Schroeter's laryngeal tubes, 263 
Schwartze operation upon mastoid, 387 
Sclerotic variety of rhinitis, 93 
Scope of laryngology, 1 
Secondary syphilis, 105 
Seiler's uvula scissors, 201 
Septal cartilage preserved in salt solu- 
tion, 54 

diseases influenced by occupation 
4i 

flap operation, 45 

operations, dangers, 43 

perforation, 57, 59 
Septum, nasal, 37 
Sequels of chronic tonsillitis, 216 
Serum treatment for diphtheria, 215 
Siegle's otoscope, 27 
Significance of past-pointing, 421 
Silver nitrate in chronic laryngitis, 252 

office supply, 33 
Simple otitis media, 350 
Simpson-Bernay tampons, 47, 68 
Sinuses of the nose, in 
Sinusitis of antrum of Highmore, 121 
Sodium perborate, 32 
Soft rubber syringe, 24 
Some hearing retained in otosclerosis, 

404 
Sound perception in cochlea, 303 

exists only where there is an ear, 
290 
Spasmodic croup, 247 
Special senses, nasal relations, 153 
Specula for nose, 24 
Speech once acquired is retained, 437 
Sphenoidal sinus, 112 

sinusitis, 141 
Sphygmomanometer, 30 



Spirochaeta pallida, 104 
Spokeshave used upon turbinals, 42 
Spontaneous cure of simple otitis 
media, 356 

cure of rhinitis, 80 
Stacke-Schwartze operation, 393 
Standard for hypodermics, 31 
Stapes guarded from injury, 376 
Static labyrinth, 406 

anatomically part of ear, 299 
Steam in diphtheria, 264 
Stearate of zinc, 35 
Sterilizers, 18 
Stirrup or stapes, 297 
Stool for surgeon, 16 
Storage battery, 20 
Styptics in epistaxis, 164 
Subjective factor in hay fever, 95 
Submucous resection of septum, 49 

use of swivel knife, 53 
Subnitrate of bismuth, 35 
Sullivan's frontal sinus rasps, 132 
Suppuration a sign of severity in 

otitis, 364 
Surgical measures in tubal obstruction, 

348 
Swivel knife used on septum, 53 
Symptoms from nosogenic region, 115 

of acute laryngitis, 245 
pharyngitis, 193 

of adenoids, 178 

of chronic nasopharyngitis, 171 

of frontal sinusitis, 129 

of inflammation, old observers, 

. 7<5 
of influenza, 100 

of labyrinthitis, 408 

of mastoiditis, 282 

of nasopharyngeal growths, 188 

of otosclerosis, 402 

of rhinitis, 70 

of simple otitis media, 355 
Syphilis in the nose, 104 
Syphilitic disfigurements, 147 

infection concerns many relations, 
261 

laryngitis, 261 



455 



Table for office, 16 

Taking cold, its significance, 78 

Tampons applied to the nares, 166 

Simpson-Bernay, 47 
Tannic acid, 32 
Teasing method in septal operation, 

Si 
Technique of adenoidectomy, 183 

of intubation, 268 

of mastoid operation, 387 

of past-pointing, 420 

of tonsillectomy, 222 

of using paraffin, 149 
Teeth penetrating maxillary sinus, 121 
Temperature affecting pharynx, 191 
Tertiary syphilis, 105 
Tests for spirochaeta pallida, 261 

of hearing by distance, 218 

with nystagmus described, 411 
Theories of inflammation, 76 
Theory of the effect of rotation test, 

4i3 
Therapeutic use of lumbar puncture, 

434 
Thiosinamine in treating cicatrices, 146 
Threefold origin of static control, 418 
Three iodine solutions, 92 

objects of aural examinations, 306 
surgical epochs, 235 
Thrombosis after paraffin injection, 

150 
in the lateral sinus, 428 
Tincture of iron chloride, ^3 
Tinnitus aurium in otitis media, 356 
Tobalt probe, 24 
Tongue depressor, 25 
Tonsil, faucial, 204 
Tonsillar oedema, 207 
Tonsillectomy, 219 
Tonsil linqual, 231 
Tonsillotome as modified by writer, 

. 228 
Tonsillotomy, 217 
Topical measures in laryngeal phthisis, 

259 



Topical remedies for chronic pharyn- 
gitis, 197 
Tracheotomy in oedema of glottis, 250 
Transillumination, 122, 130 
Traumatic disfigurements, 146 

epistaxis not trivial, 162 
Traumatism of auricle, 338 
Treatment after adenoidectomy, 187 

after Killian operation, 136 

after tonsillectomy, 230 

of acute pharyngitis, 193 
tonsillitis, 208 

of adenoids, 183 

of cholesteatoma, 371 

of chronic nasopharyngitis, 173 

of diphtheria, 104 

of epistaxis, 163 

of extra-dural abscess, 427 

of hyperkeratosis, 213 

of influenza, 100 

of laryngitis, 245 

of neuroses of the larynx, 285 

of otomycosis, 240 

of rhinitis, 81 

of simple otitis media, 356 

of syphilis, 108 

of uvulitis, 200 
Trichloracetic acid, 86 
True vocal cords, 238 
Tuberculosis of the nose, 109 
Tumors in the nasopharynx, 188 
Tuning fork, 28 

forks used in testing hearing, 320 
Turbinals enlarged in septal disease, 42 
Tyler-grip, 99 
Tympanum, 295 

normally an aseptic cavity, 350 



V 



Ulcerative tonsillitis, 211 

Unique value of history in aural cases 

307 
Use of mouth by infants, 279 
Utilization of remnants of hearing, 44' 
Uvula, 198 
Uvulitis, 199 



456 



INDEX 



\\ 



Vacuum aspirator, 23 

Valsalva's method of inflation, 311 

Variations in structure of ear, 289 

Varied forms of laryngeal paralysis, 
288 

Varieties of influenza, 100 

Various causes of nausea and vertigo, 
409 

Varix upon lingual tonsil, 232 

Vaso-motor rhinitis, 95 

Vertigo in relation to brain disease, 424 

Very slow progress of cancer of ear, 341 

Vibration present everywhere, 290 

Vicarious bleeding, 161 

Vincent's angina, 121 

Vocal cords, 238 

Vocalization, proper and improper, 196 

Voice in tests of hearing, 320 

similar in all races of men, 243 
standardized by phonograph, 322 

Vomer, removal, 55 

Vomiting during anaesthesia, 280 

Von Bergmann's area, 430 



Warnings of mastoid disease, 378 
Wash stand for office, 17 
Wassermann's test for syphilis, 105 
Watch tick in tests of hearing, 320 
Weakness of restored septum, 61 
Weber test of hearing, 324 
Whiskey, 82 

Whistle, Dench's or Galton's, 28 
Whistling sound in septal perforation, 

58 
Witch-hazel, 87 

X 

X-ray in search for foreign bodies, 73 

Y 
Yankauer's operation, 88 

Z 

Zinc salts in chronic laryngitis, 252 
stearate, 35 



